Wv Dui Safety - Treatment Program Indigent Determination Packet Page 2

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Bureau for Behavioral Health &Health Facilities (BBHHF)
Bureau for Behavioral Health &Health Facilities (BBHHF)
Bureau for Behavioral Health &Health Facilities (BBHHF)
Fiscal Procedure 1001
DUI Safety & Treatment Program Indigent Determination Procedure
DUI Safety & Treatment Program Indigent Determination Procedure
DUI Safety & Treatment Program Indigent Determination Procedure
Application - Page 1
WV DUI S & T PROGRAM
INDIGENT
INDIGENT DETERMINATION FORM
APPLICATION DATE: _ ____/_____/________
____/_____/________
DRIVER’S NAME:
BIRTHDATE:
DRIVER LICENSE #:
Issuing State
DRIVER’S ADDRESS: Street:
City:
State:
Zip code:
TELEPHONE NUMBER: (
)
-
DEPENDENTS LIVING IN HOUSEHOLD
DEPENDENTS LIVING IN HOUSEHOLD (name and relationship):
Name:
DOB
Relationship
Received 12/6/2011 from
Lisa Bruer, WVBHHF DUI Program Coordinator

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