Family Size And Address Verificaiton Form July 2000 printable pdf download

Family Size And Address Verificaiton Form July 2000

FAMILY SIZE AND ADDRESS VERIFICATON

I HEREBY Certify, under the penalty of perjury that I _________________________________,

reside at ________________________

________________________

_______________

Physical address

City

State

and that my family size is: __________________.

Listed below are the family member (s), their relationship and/or decree of court that are my

dependents:

Family Member

Relationship/Court Decree

1.__________________________

__________________________

2.__________________________

__________________________

3.__________________________

__________________________

4.__________________________

___________________________

5.__________________________

___________________________

6.__________________________

___________________________

I attest that the information stated above is true and accurate, and understand

that the above information if misrepresented or incomplete may be grounds for

immediate termination and/or penalties as specified by law.

_____________________________________

___________________________________

Applicant’s Signature

Witness’ Signature

______________________________

Witness’ Relationship to Applicant

PERSON SIGNING AS COLLABORATING WITNESS MUST NOT BE LIVING IN THE

SAME HOUSEHOLD.

The above information is being utilized for address verification and family size.

__________________________________

__________________

Signature of SCSEP Interviewer

Date

7/20/00

F:\Website\employ\AddressVerify.doc

Family Size And Address Verificaiton Form July 2000