Scsep Third Party Attestation Forms - U.s. Department Of Labor Page 11
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12Third-Party Attestation Form for Item E6
If exit is not due to unsubsidized employment, other reason for exit
On this date, I attest that __________________________________________
(Name of Participant)
_____ is deceased.
_____ is unable to continue participating in the SCSEP program and unable to work based on one of the
following statements:
_____ He/She has a documented health/medical exclusion, that is:
1. he/she is in the care of Dr. ____________________
and
(Name of Doctor),
2. I have been informed by Dr. ____________________
that
(Name of Doctor)
a. his/her medical condition is expected to last at least 90 days, and
b. his/her medical condition prevents him/her from continued participation in the SCSEP
program and from working.
_____ He/She has a documented family care exclusion, that is:
1. he/she is providing care for _____________________________
(Name of Relative and
, who is a member of his/her family, and
Relationship to Participant)
2. the family member is in the care of Dr. ____________________________
(Name of
, and
Doctor)
3. I have been informed by Dr. ____________________________
that the
(Name of Doctor)
medical condition is expected to last at least 90 days, and
4. the family member requires a level of care which prevents me from continued
participation in the SCSEP program or from working.
_____ He/She is institutionalized, that is:
1. he/she is receiving 24-hour care at _________________________ (
,
Name of Facility)
which is a facility such as a prison or a hospital, and
2. I have been informed by _____________________________
that he/she
(Name and Position)
is expected to remain at this facility for at least 90 days, which prevents him/her from
continued participation in the SCSEP program and from working.
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 11 of 12
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