Child Support Income Verification Letter Template
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1CHILD SUPPORT INCOME VERIFICATION LETTER
FROM:
Shands Jacksonville
OP Financial Services
2000 Boulevard Street
Jacksonville, FL 32209
DATE: _________________________
TO:
Child Support Enforcement
Duval County Jacksonville Division
921 N. Davis St. Bldg. A Rm.# 350
Jacksonville, FL 32209
To Whom It May Concern:
The following applicant has applied for medical assistance. Our agency is required to conduct a
.
third party verification of all applicants applying for assistance
STATEMENT OF AUTHORIZATION:
I, _________________________________, authorize the Department of Revenue to release
any information or materials which are deemed necessary to complete my determination of
eligibility for services.
___________________________
_______________________
__________
Name of Applicant
Signature of Applicant
Date
(Printed)
___________________________
_________________________
__________
Date
Social Security Number of Applicant
Agency Representative
(Signature)
---------------------------------------------------------------------------------------------------------------------
DOR VERIFICATION:
____ The above mentioned person has not registered with our agency or has not
received child support payments.
____ Find attached records on child support paid to custodial family for the past 12 months
___________________________
_______________________
__________
DOR Representative
Title
Date
(Signature)
Revised 3/19/09
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