Aarp Foundation Web Based Scsep Application Form (Page 6 of 7) in pdf

Aarp Foundation Web Based Scsep Application Form Page 6

Residence /Family Size

Certificate

Important: Must be completed by a non-family member, such as Apartment Manager, Property Owner, Clergy, Social Worker, etc.

I, the undersigned, certify that to the best of my knowledge the Applicant/Participant resides

the address listed below.

Applicant’s/Participant’s Name

Applicant’s/Participant’s Street Address

Apt.

City

State

ZIP Code

I understand that in applying for the AARP Foundation, Senior Community Services Employment Program, the

information I provided above will be used to determine the applicant’s eligibility under applicable Federal Laws

and Regulations. I further certify that the information provided above is true and correct, to the best of my

knowledge.

I understand that any changes to the application/participant’s residency is to be reported to the AARP

Foundation SCSEP as the changes may affect his/her eligibility for this program. AARP Foundation SCSEP may

contact me at the address and telephone number provided below if additional information is needed.

The number of people living together with him/her in the Family:

Two or more persons related by blood, marriage or decree of court, residing

in a single residence and who are included in one or more of the following

categories:

A husband, wife, and dependent children



A parent or guardian, and dependent children



A husband and wife



Claiming dependent(s) that are listed on the 1040

Signature

Date

(

)

Your Name (Please Print)

Your Telephone

Your Street Address

City

State

Zip Code

Your Relationship to Applicant/Participant

Revised: 9/21/2011

Aarp Foundation Web Based Scsep Application Form Page 6