Income Verification Waiver.pdf

Lack-of-Income-Verification-Credible-Print-Vers.pdf
Preview of Income Verification Waiver
🔗 Source: fourcounty.com
📊 Size: 311 KB
👤 Author: Valerie Patton
⬇️ Downloads: 150

Summary

I certify that I have no income from any source and agree to notify Four County Mental Health Center if my income status changes. I understand that third-party verification is preferred for the sliding fee scale, but self-declaration is permitted when third-party verification cannot be obtained, with documentation of the attempt required.

Description

I certify that I have no income from any source and agree to notify Four County Mental Health Center if my income status changes.

Technical Information

  • File Format: PDF
  • File Size: 311 KB
  • Pages: 1
  • Language: EN
  • Author: Valerie Patton
  • Total Downloads: 150
  • Last Updated: 1 month ago

Document Overview

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