Form 4469-2026

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The document is a form from the New York State Department of Health for applicants to report their financial status related to self-employment income for Medicaid and Family Health Plus enrollment. It outlines the required information on business income, expenses, and net income over three months, along with instructions on allowable deductions and a certification statement for accuracy.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name, address, and contact information in the designated fields at the top of the form. Ensure accuracy as this information is crucial for processing.
In the 'Business Income' section, input your gross sales and inventory purchases for the last three months. The platform will automatically calculate your gross income by subtracting inventory purchases from gross sales.
Next, move to 'Business Expenses.' Fill in each expense category such as telephone, supplies, and utilities. Be mindful of allowable deductions as specified in the notes.
After listing all expenses, review the 'Income Summary' section where total business expenses and net income will be calculated based on your entries.
Finally, ensure you sign and date the certification statement at the bottom of the form to confirm that all provided information is accurate.

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