Annual Income Verification
Client Name
*
First Name
Last Name
Client's Date of Birth
*
Please select a month
January
February
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Month
Please select a day
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Day
Please select a year
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Year
IF you have other family members that are enrolled in services? Please list names and dates of birth below and we will apply this information to all the accounts.
Do you have insurance?
*
YES
NO
Copy of the front of the insurance card
Copy of the back of the insurance card
Income Information
In order to process your annual income verification we need proof of family income. This is for the client and spouse (if married); for children under 18 it would be for parents that are living in the household and working. For any children still living at home that are over the age of 18--we only need the client's income. Please check all those that apply to your household.
*
Social Security--please provide a copy of your award letter
Monthly pension statement
Unemployment
Employment income--verified with Tax Return or W2
Employment income--verified with last 4 pay stubs
Not currently working--family has no income--please have someone complete and then take a picture of the No Income Letter included with your letter.
Please take a photo of your social security letter
Please take Photo of your pension statement or bank statement showing the deposits
Please take a photo of your unemployment letter or your bank statement showing the deposits.
Please take a photo of your W2 or Most recent Tax Return
Take a photo of Paystub #1
Take a photo of Paystub #2
Take a photo of Paystub #3
Take a photo of Paystub #4
Take a photo of Additional Pay Information
Take a photo of Additional Pay Information
Take a photo of Additional Pay Information
Please take a photo of the no income letter
How many people are in your household? This is the immediate family--adults in the household and children under the age of 18. It does not include any extended family.
Name of the person completing this form and relationship to client.
By Signing Below I am attesting that the information contained is accurate and that the agency has permission to use this information to calculate my eligibility for the sliding fee. A copy of my sliding fee will be mailed to the address on file.
Date
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Month
-
Day
Year
Date
Submit
Should be Empty: