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APPENDIX E: HEALTHPAC VERIFICATION DOCUMENTS
Enrollment in HealthPAC requires documentation to prove:
1. Identity
2. Alameda County residency
3. Income
• Applicants DO need to provide:
o One identity document from the list
o One Alameda County Residency document from the list
o One income document from the list
o One document from the residency and income list fulfills both requirements
• The HealthPAC Statement of Income and Residency can be used to establish residency and income if all attempts
have been made to get other documentation.
• In rare cases, the HealthPAC Statement of Income and Residency can also be used to establish identity.
Appendix E: HealthPAC Verification Documents (January 2026) 2
IDENTIFICATION
1. A recent and valid California or out-of-state motor vehicle Driver’s License
2. Identification card issued by the Department of Motor Vehicles
3. Voter’s Registration Card from another country which has a picture and name
4. Check cashing card with photo
5. School identification card with photo
6. Work badge, building pass with photo
7. Consulate identification card (Matricula Consular)
8. Tribal enrollment card with photo
9. Border crossing card with photo
10. U.S. Military Identification Card or draft record
11. Federal, state, or local government I.D. card with same identifying information as a driver’s license
12. U.S Military dependent identification card
13. Certificate of Degree of Indian Blood or other U.S American Indian/Alaska Native Tribal
14. U.S Coast Guard Merchant Mariner Card
ALAMEDA COUNTY RESIDENCY
(Current verification as an Alameda County resident includes but is not limited to)
1. Current utility bill in applicant’s/family name
2. A current and valid California motor vehicle registration in applicant’s/family’s name
3. A recent Alameda County rent or mortgage receipt or current lease
4. Paycheck stub w/home address
5. Bank account statement with home address
6. School registration printout with home address
7. Sworn statement from relative/friend with whom they are living, along with a utility bill in their name if possible
8. Homeless applicants should use the HealthPAC Statement of Income and Residency form to state they are homeless in
Alameda County
If a P.O. Box is used for mailing address, must provide verification of residential address
HealthPAC Statement of Income and Residency form only when no other verification exists
Appendix E: HealthPAC Verification Documents (January 2026) 3
INCOME
(Preferably one month worth of income from less than 45 days ago)
1. Paycheck stubs (gross earnings including tips, commission, meal-in/dine-in. In certain circumstances HealthPAC may
request additional pay stubs).
2. Statement from provider of other income (contributions, gifts, loans, refunds, child support, alimony etc.) State Disability:
check stubs or award letter
3. Self-employment information: last year’s 1040 tax return (refer to Appendix D)
4. State unemployment: check stubs or award letter
5. Worker’s Compensation: check stubs
6. Retirement/pension benefits: check stubs or awards
7. Rental income: 1040 Tax return line 8, Schedule E or HealthPAC Statement of Income and Residency form if not claimed on
taxes.
8. Personal checks count as cash income. Applicant should also complete the HealthPAC Statement of Income and Residency
Form
9. Letter from employer stating amount and frequency of payment, signed and dates
10. Other income – complete the HealthPAC Statement of Income and Residency form
HealthPAC Statement of Income and Residency form only for declaring no income, cash income, or other unverifiable income
ALAMEDA COUNTY RESIDENCY AND INCOME
1. State Unemployment check stubs or award letter with home address
2. State Disability check stubs or award letter with home address
3. Worker’s Compensation check stubs with home address
4. Retirement/pension benefits check stubs or award letters with home address
5. Income tax documentation from prior calendar year (1040 only) with current home address
6. Current check stub with home address