Notarized Food, Shelter And/or Monetary Verification Form

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NOTARIZED FOOD, SHELTER AND/OR MONETARY VERIFICATION FORM
I, _________________________________________________________________________________________who reside at:
(Print Name of Individual PROVIDING Assistance)
___________________________________________________________________________________________________________________
(Street Number and Name)
(Apt #)
(City)
(State)
(Zip Code)
declare that I have provided the following (Please Check all that Applies)
____ FOOD
____ FOOD AND SHELTER
____ SHELTER
And I have provided this at /AND
____NO CHARGE
and/or
____ I GIVE $____________ PER MONTH/ or _______
and/or
____ I CHARGE $___________ PER MONTH
and/or
____RENT BEHIND SINCE _______________________
Beginning date: ________________________________
Ending date: ________________________________
(Do not notate an end date if assistance is ongoing)
For ____________________________________________________________________________who resides at:
(Print Name of Individual RECEIVING Assistance)
________________________________________________________________________________________________
(Street Number and Name)
(Apt #)
(City)
State)
(Zip Code)
Relative to Patient ______ yes ______ no
X_______________________________________________
Signature of Individual PROVIDING assistance
STATE OF __________________, COUNTY OF ____________________.
The foregoing instrument was acknowledged before me this _____________________ by (date)
_____________________________________________, who is personally known to me or who has produced
(Print Name of Individual PROVIDING Assistance)
__________________________________________ and expiration date_______________________ of identification.
(Form of Identification)
and took an oath attesting that the above information is true, exact and complete, and that to the best of their knowledge the
information they have provided is not false or fictitious whatsoever.
________________________________________________________
Notary Signature
Seal/Stamp:
NOTICE OF FLORIDA HOSPITAL FRAUD LAW
(1) Whoever shall, willfully and with intent to defraud, obtains or attempts to obtain goods, products, merchandise or services from
any hospital in this state shall be guilty of a misdemeanor of the second degree, punishable as provided bin 775.082 or 775.083.
(2) If any person shall give to any hospital in this state a false or fictitious name, a false or fictitious address, any other false or
fictitious information required to be obtained by such hospital in compliance with 382.31 et seq., or shall assign to any hospital the
proceeds of any insurance contract, then knowing that such contract is no longer in force or is invalid or is void for any reason, any
such action shall be prima facie evidence of the intent of such a person to defraud such hospital. VIOLATION of Florida Statute
817.50 is punishable by imprisonment not exceeding sixty (60) days or fine not in excess of $500.00, or both, as may be provided by
law upon conviction.
*THIS DOCUMENT MUST BE COMPLETED AND NOTARIZED WITHIN** 7 DAYS OF THE SCHEDULED FINANCIAL EVALUATION APPOINTMENT.

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