Wv Dui Safety - Treatment Program Indigent Determination Packet Page 3
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1
2
3Bureau 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 2
WV DUI S & T PROGRAM
INDIGENT DETERMINATION FORM
INDIGENT DETERMINATION FORM - FINANCIAL STATEMENT
FINANCIAL STATEMENT
FAMILY INCOME** BY SOURCE
FAMILY INCOME** BY SOURCE
Driver Name:
Date of Birth:
TOTAL
DRIVER
SPOUSE
ANNUAL SALARY (GROSS)
UNEMPLOYMENT BENEFITS
SOCIAL SECURITY BENEFITS
INVESTMENTS
WORKERS COMPENSATION
CHILD SUPPORT
OTHER (ALIMONY, ETC.)
OTHER
TOTAL
TOTAL FAMILY INCOME $
(from above)
TOTAL FAMILY MEMBERS
(from page 1)
The above two data elements will be utilized to determine Indigent Status based on
The above two data elements will be utilized to determine Indigent Status based on
The above two data elements will be utilized to determine Indigent Status based on current
federal poverty guidelines.
Please provide one or more of the documents described in section 4.2 (items a
Please provide one or more of the documents described in section 4.2 (items a
Please provide one or more of the documents described in section 4.2 (items a -d) of this
procedure to verify the information reported.
procedure to verify the information reported.
***************************************
***************************************
I HEREBY ACKNOWLEDGE THAT THE INFORMATION GIVEN HEREIN IS TRUE AND
I HEREBY ACKNOWLEDGE THAT THE INFORMATION GIVEN HEREIN IS TRUE AND
I HEREBY ACKNOWLEDGE THAT THE INFORMATION GIVEN HEREIN IS TRUE AND
CORRECT. I AUTHORIZE THE DUI SAFETY & TREATMENT ENROLLED PROVIDER TO
AUTHORIZE THE DUI SAFETY & TREATMENT ENROLLED PROVIDER TO
AUTHORIZE THE DUI SAFETY & TREATMENT ENROLLED PROVIDER TO
VERIFY ANY INFORMATION CONTAINED IN THIS DOCUMENT FOR THE SOLE PURPOSE
INFORMATION CONTAINED IN THIS DOCUMENT FOR THE SOLE PURPOSE
INFORMATION CONTAINED IN THIS DOCUMENT FOR THE SOLE PURPOSE
OF ASSESSING FINANCIAL NEED.
OF ASSESSING FINANCIAL NEED.
____________________________________________________________
____________________________________________________________
____________
____________
SIGNATURE OF PERSON M AKING REQUEST__________________________DATE ________
AKING REQUEST__________________________DATE ________
AKING REQUEST__________________________DATE ________
Received 12/6/2011 from
Lisa Bruer, WVBHHF DUI Program Coordinator
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