EARNINGS/HOUSING VERIFICATION FORM Financial Support and/or Housing: _________________ is providing financial support and/or housing for me/my household. Signature of Financial Supporter/Housing Provider_______________________ (PLEASE CIRCLE ONE) Date___________ ____________________________________________ I, ______________________, verify that I am not receiving any source of income and the above information is true and accurate to the best of my knowledge. I acknowledge that any false information on this form may revoke any decision made on my Access-to-Care application. Signature of Applicant________________________ Date_____________ Signature of Co-Applicant_____________________ Date_____________ Please contact our financial counselors at (207) 498-1371, (207) 498-1617, or (800) 858-2279 ext 1371 or 1617 if you have any questions regarding this form.
EARNINGS/HOUSING VERIFICATION FORM Financial Support and/or Housing: _________________ is providing financial support and/or housing for me/my household. Signature of Financial Supporter/Housing Provider_______________________ (PLEASE CIRCLE ONE) Date___________ ____________________________________________ I, ______________________, verify that I am not receiving any source of income and the above information is true and accurate to the best of my knowledge. I acknowledge that any false information on this form may revoke any decision made on my Access-to-Care application. Signature of Applicant________________________ Date_____________ Signature of Co-Applicant_____________________ Date_____________ Please contact our financial counselors at (207) 498-1371, (207) 498-1617, or (800) 858-2279 ext 1371 or 1617 if you have any questions regarding this form.
pines-earnings-housing-verfication-form-071015-2.docx