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California attestation form

Attestation non form 2026

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The document is an attestation form from Covered California, where applicants declare their non-incarceration status to qualify for affordable health insurance, including Medi-Cal. It requires the applicant's printed name, signature, and date, along with instructions for submitting the form via fax or mail.

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Click ‘Get Form’ to open the attestation non form in our editor.
In the first field, enter your Case Number. This is essential for identifying your application.
Next, in the section labeled 'Applicant’s Printed Name', clearly print your full name to attest your identity.
Read the statement regarding incarceration carefully. Ensure you understand that you are declaring you are not currently incarcerated.
Sign in the 'Applicant’s Signature' field to confirm your attestation. Make sure your signature matches your printed name.
Finally, input today’s date in the format MM/DD/YYYY to complete the form.

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