Snake River Community Clinic

Available Forms

Dental Care Request Medication Refill Request Form Patient Health Questionnaire - Depression Screening Patient Intake/pre-appointment Form Self-Attestation Income Verification

Self-Attestation Income Verification

Today's Date *

Patient's First Name *

Patient's Last Name *

Date of Birth *

Snake River Community Clinic is required to verify the household income of patients accessing services.

Snake River Community Clinic is required to verify the household income of patients accessing services. *

I get paid in cash, do not receive my pay stub and my employer will not provide me a letter confirming my payment.

I am self-employed and do not file taxes.

I do not receive any income.

I receive income.

I hereby certify that I (and my family) receive the following income. I understand that I need to provide proof of income annually. I understand sources of income include, but are not limited to, the following: wages, salaries, and tips; Social Security benefits; Unemployment compensation; Self-employment or business income; Alimony; Retirement and pension income; Investment and rental income; Other taxable income.

Print Name

Please indicate your gross monthly income: *

Number of household members: *

I hereby certify that I (and my family) do NOT receive the following income from ANY source. I understand sources of income include, but are not limited to, the above list.

Print Name

Please explain below how you (or your family) have paid for these two living expenses when your household has had no income. Utilities: Housing:

I do hereby swear or affirm that the information provided on this application is true and correct to the best of my knowledge and belief. I agree that any misleading or falsified information, and/or omissions may disqualify me and my family from further consideration free services. I further agree to inform Snake River Community Clinic if there is a significant change in my income. I hereby acknowledge that I read and understand the foregoing disclosure.

Patient's Signature *

Please read the above statement and acknowledge by typing your name here.

Date *

* Required field