Www.dhs.state.il.us
Income Statement
for Persons Who Are Paid in Cash
You must prove how much money you get from work to get All Kids health insurance for your children. If you are paid in cash, ask your employer to write down how much and how often you are paid and give us the statement
Use this form to tell us how much you are paid if your employer will not give you a written statement. You may use this form if you think you may lose your job if you ask your employer for proof.
Fill out all the blanks.
Your name __________________________________________________
(First and Last Name)
What kind of work do you do?____________________________________________________
Mark one of the boxes below to tell us how often you get paid.
I get money each day I work. I get money each week I work.
I get money every other week. I get money two times a month.
I get money once a month. I get money when the work for the season is done.
Other _____________________
When were you paid last? ________________ How much were you paid? $ _______________
How much were you paid in each of the last three months? We need to know this if you want health insurance for those months.
Month Amount Paid
________ $___________
________ $___________
________ $___________
Sign your name below and write today’s date.
_________________________________________________ Date: _______________________
(Signature of person getting cash for work)
For office use only: All Kids #__________________________ Csld: _________
HFS 266AK (N-04-06) IL 478-1882
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