Employment And Wage Verification Form (Page 4 of 5) in pdf

Employment And Wage Verification Form Page 4

INCOME ASSISTANCE VERIFICATION FORM

We are trying to determine the eligibility of ________________________________________ for services at the

Wilkes Public Health Dental Clinic.

_____________________________________ reports her/him and her/his family has little or no income. Before

we can determine eligibility, we need a third party to confirm this. By signing this letter, you are confirming that

to the best of your knowledge, this individual/family has little or no income.

Thank you for helping us determine eligibility for this individual/family through our programs. If you have any

questions, please call 336-903-9399 or fax information to 336-903-7313.

______________________________________ ____________________________ __________

Staff Signature

Title

Date

RELEASE: I hereby authorize the release of the requested information. Information obtained under this consent

is limited to information that is no older than 12 months.

____________________________________________

___________________________

Client Signature

Date

Please complete the following:

Date of Assistance _____________________________

Amount Per Month

Income:

Source ______________________________

$_______________

Source______________________________

$_______________

Comments: __________________________________________________________________________________

______________________________________________

_______________________________________

Third-Party Signature

Date

______________________________________________

________________________________________

Print Third-Party Name

Individual/Agency/Organization

Third-Party Address ___________________________________________________

___________________________________________________

Third-Party Phone # ___________________________________________________

For applicants with no income see statement on back

Employment And Wage Verification Form Page 4