D-1070, Documentation Requirements

Revision 15-4; Effective October 1, 2015

CHIP, CHIP Perinatal

Exempt Income


  • why it is exempt, and
  • the name and address or telephone number of the income source.

Terminated Income


  • the name and address or telephone number of the income source, and
  • vacation pay received before or after termination, including the dates received.


Document the:

  • date of each income statement or stub used;
  • date income is actually received;
  • date income is anticipated using factors such as time it has to travel via mail, weekends and holidays;
  • name and address or telephone number of the income source;
  • gross amount of income;
  • frequency of receipt (such as weekly, every two weeks, semi-monthly, monthly); and
  • calculations used.

Income Computations

Document verification and computation of household income at the initial application, when a change is reported and at each subsequent application/redetermination. Record all sources, amounts, dates and computations.

Other Income

Document the method used to verify income other than earned income. This documentation includes the type of income, the check or document seen, the date on the check or document, the amount recorded on the check or document, the date the income was verified and any computations performed to determine the total income.



  • the method for averaging income;
  • deductions for the cost of doing business;
  • the number of hours engaged in the enterprise;
  • other factors used to determine the amount of income;
  • that the individual was informed to keep self-employment records and receipts for verification purposes for future recertifications; and
  • when using Form H1049, Client's Statement of Self-Employment Income, as the only source of verification, the reason Form H1049 is the only source of income.