Non Incarceration Status Form PDF Details

For those with a criminal history, obtaining non-incarceration status can seem daunting at first. Although the process may be complex and time consuming, having your record reclassified as “non-incarcerated” can provide greater opportunities when applying for jobs, housing or education. To start this process, you must fill out an official Non Incarceration Status Form in its entirety - but understanding these forms and how to best complete them is far from simple. In our next blog post, we'll break down the form step by step so that you'll understand exactly what's involved in obtaining a non-incarceration status record.

QuestionAnswer
Form NameNon Incarceration Status Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namescalifornia attestation form, attestation non status, attestation covered form, ca attestation covered

Form Preview Example

COVERED CALIFORNIA

P.O. BOX 989725

WEST SACRAMENTO, CA 95798-9725

Your destination for affordable

health insurance including, Medi-Cal

Case Number: __________________

ATTESTATION OF NON INCARCERATION STATUS

“I, _____________________________, do hereby attest that I am not currently incarcerated.

(Applicant’s Printed Name)

This means that I am not confined, after the disposition of charges (judgement), in a jail, prison or similar penal institution or correctional facility. If I have recently been incarcerated, but since released from incarceration, I understand that I can sign and submit this form to Covered California to provide attestation that I am no longer incarcerated.”

I declare under the penalty of perjury, under the laws of the State of California, that what I stated above is true and correct

Applicant’s Signature: _____________________________________ Today’s Date: ___ /___ /____

MM DD YYYY

Send your form two ways:

1.Fax to: 888-329-3700 (888-FAX-3700)

2.Mail to:

Covered California

PO BOX 989725

West Sacramento, CA 95798-9725

PAGE 1

How to Edit Non Incarceration Status Form Online for Free

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1. To start with, while completing the attestation non status, start out with the area containing following blank fields:

Stage number 1 for filling out attestation covered form

2. Once your current task is complete, take the next step – fill out all of these fields - Applicants Signature Todays Date, Send your form two ways Fax to, Covered California PO BOX West, and Page with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

attestation covered form writing process described (stage 2)

It is easy to make an error when filling in your Covered California PO BOX West, for that reason make sure you reread it prior to deciding to submit it.

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