Scsep Third Party Attestation Forms - U.s. Department Of Labor Page 10
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12Third-Party Attestation Form for Item P45
Total includable family income (12 month or 6 month annualized) at recertification
On this date, I attest that __________________________________________
(Name of Participant)
had a “family income” (the combined income of his/her current family members, including parent,
guardian, husband, wife, and/or dependent children, if applicable) of zero for the past
( ) six months
( ) twelve months
He/she has supported his or her self during this period of time as follows:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Specific information about your relationship to the applicant and an explanation of how you are in a
knowledgeable position to attest to the facts cited above is required. Please provide this information
below (Note: Use the back of this form if additional space is needed):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_____________________________________
_____________________________________
(Name of Attesting Individual)
(Relationship of Attesting Individual to Participant)
_____________________________________
___________________
(Signature of Attesting Individual)
(Date)
SCSEP Third Party Attestation Forms
page 10 of 12
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