Scsep Third Party Attestation Forms - U.s. Department Of Labor Page 3

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Third-Party Attestation Form for Item P11
Number in family
On this date, I attest that ______________________________
has
(Name of Applicant)
______ people living with him/her as part of his/her family.
Specific information about your relationship to the applicant and an explanation of how you are in a
knowledgeable position to attest to the fact(s) cited above is required. (Note: Use the back of this form
if additional space is needed):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_______________________________________
________________________________________
(Name of Attesting Individual)
(Relationship of Attesting Individual to Applicant)
___________________________________
_____________________
(Signature of Attesting Individual)
(Date)
SCSEP Third Party Attestation Forms
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