| Shawnee’s Financial Assistance Program Attestation |
SHAWNEE HEALTH SERVICE
Applicant Name: ________________________________________________________________________ Date of Birth: _________________________
Complete Any Applicable Item below:
- Please list the names of those that you support in the household and their relationship to you.
____________________________________________________________________________________________
____________________________________________________________________________________________ - If someone else helps support you, please list the names and their relationship. Have that individual who supports you complete the following information:
Name of individual: ____________________________________________________________________________________________
Relationship to you: ____________________________________________________________________________________________
Type of support provided (housing, food, clothing, transportation, etc.): _____________________________________________________________
Signature of individual that supports you: ____________________________________________________________________________________________
Telephone: ____________________________________ Date: _________________________ 
I am unemployed I work intermittently I am a farmworker- I am paid in cash. Employer Verification of Income: Your employer will be contacted to verify wages.
Employer Name: ____________________________________________________________________________________________ Phone: ________________________________
Gross Earnings (Before Taxes): _____________________________________________________________
Frequency of Pay (Weekly, Bi-Weekly, Monthly, Bi-Monthly, Annually): _____________________________________________________________ - I do not file taxes because my only source of income is Social Security/Disability benefits.
- Other: ____________________________________________________________________________________________
AGREEMENTS: By signing below, I agree that
- I certify that the information I provide is true and correct and that if the information proves to be incorrect, the discount will be denied.
- I understand the information may be reviewed by an auditor of any patient assistance program that I may benefit from.
- I authorize my employer, named above, to disclose my income with Shawnee Health Service for the purpose a sliding fee program.
Applicant Signature: ____________________________________________________________________________________________ Date: _________________________
Applicant Signature: ____________________________________________________________________________________________ Date: _________________________
Staff signature: ____________________________________________________________________________________________ Date: _________________________
Interpretation Provided By: ____________________________________________________________________________________________