Scsep Third Party Attestation Forms - U.s. Department Of Labor Page 9

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Third-Party Attestation Form for Item P44
Number in family at recertification
On this date, I attest that __________________________________________
(Name of Participant)
has ______ 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 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 9 of 12

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