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Income Disclosure Form

Complete and sign the income disclosure form below to request a reduction in your contribution rate. The NHIB will review the form and take appropriate action upon receiving it.

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Income Disclosure Form

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  1. Income Disclosure Form Instructions: Please complete and sign the form below, providing all requested information. Pending receipt of the completed and signed form, the NHIB will review the request for a reduction in your contribution rate and action accordingly. Last Name: ________________________ First Name: ________________________ Middle Name:_______________________ DOB (mm/dd/yyyy): _____________________ NIB Number: _____________________ NHIP Number: ___________________ Address: ________________________________________________________________________________________________ Area: ____________________ Island: ________________ Phone: _________________ E-mail: ________________________ Occupation/Nature of Self-Employment Work (please be as specific as possible): _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ In the table below, please provide details pertaining to your self-employment income during the past 3 months. DECLARATION I, _______________________________________________________ (full name of self-employed person), hereby declare that to the best of my knowledge, the above information is true and accurate. In addition, I hereby affirm that I am able to substantiate the foregoing information (via bank statements, etc., which I will provide to the NHIB upon request). Print name: ___________________________________ Signature: ____________________________________ Date (mm/dd/yyyy): ________________________ INTERNAL OFFICE USE ONLY Revised Contribution Amount: _________________________________________________________ Effective Date: _____________________________________________________________________ Authorized By: Print name: ___________________________________ Signature: ____________________________________ Date (mm/dd/yyyy): ________________________

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