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SFAP Attestation

Shawnee’s Financial Assistance
Program Attestation

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SHAWNEE HEALTH SERVICE

 

Applicant Name: ________________________________________________________________________  Date of Birth: _________________________

Complete Any Applicable Item below:

  1. Please list the names of those that you support in the household and their relationship to you.
    ____________________________________________________________________________________________
    ____________________________________________________________________________________________
  2. 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: _________________________
  3. Checkbox  I am unemployed      Checkbox  I work intermittently      Checkbox  I am a farmworker
  4. Checkbox  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): _____________________________________________________________
  5. Checkbox  I do not file taxes because my only source of income is Social Security/Disability benefits.
  6. Checkbox  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: ____________________________________________________________________________________________

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