Statement Of Earnings - Mhmra Of Harris County, Texas printable pdf download

MHMRA OF HARRIS COUNTY

STATEMENT OF EARNINGS

This is an Official Government Record. Untrue or incomplete information given on this form may and

probably will result In Criminal Action being taken under Section 31.04, 37.04, 37.10, or other portions of

Texas Penal Code. Fill out only the sections that apply to you. Be sure to fill-in every space in those

sections. This is an Official Government Record.

SELF-EMPLOYED PERSON

I, ________________________________________________________________________, am presenting

(1040, Bookkeeper Stat, Receipt, etc.) ____________________________________ to prove my total gross

monthly income which is $____________________. My profession is ____________________________.

Additional income for my immediate family comes from ________________________________________

and totals $_________________. I (We) have no other source of income including savings, real property

or rental property.

SEPARATED PERSON

I, _________________________________________________ acknowledge that I have been separated for

(months/years) _____________________________, from (full name) _____________________________,

of (street address) _______________________________ (city) ________________ (state) _____________

(zip code) _________ who earns $ ___________. Additional income for my immediate family comes from

_________________________________________ and totals $ _______________. I have no other source

of income including savings, real property or rental property.

HOMEMAKER

I, ________________________________________________, am a homemaker. I do not earn any income

in or out of my home. The last date I worked was __________________________.

Name of Employer: __________________________________ Address: ___________________________

Telephone Number of Employer: _____________________________. I am not on leave of absence from a

job. I have been a homemaker for the following length of time: ________________________. My support

is _______________________. I have no other source of income including savings, real property or rental

property.

(By signing this acknowledgement, you understand that this data will be placed in a shared data repository

to assist in qualifying for indigent health services.)

Signature: ___________________________________________Date: ____________________________

Statement Of Earnings - Mhmra Of Harris County, Texas