Application For Health Care Assistance Page 7
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FMED
Other information and referrals
.
.
I give my word, under penalty of perjury, the information I give in this application is true and complete to the best of
my knowledge and belief. I have read and I understand the Rights and Responsibilities on the back of this application
and I agree to them.
Signature of applicant
or authorized representative
Date
Signature of person helping
fill out this form
Date
Return this application to:
DCF/Economic Services Division
Application and Document Processing Center
103 South Main Street
Waterbury, VT 05671-1500
For questions call 1-800-250-8427, (TTY/TDD 1-888-834-7898) or your local Department of Health office.
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