I,   First Name   Last Name (the SUPPORTER) certify and attest to Sinclair Health Clinic that I have been providing housing to  First Name   Last Name  (the APPLICANT) at the following location:   Street Address      City   State   Zip, and for the following period of time:   Please Select123456789101112   Please Selectmonth(s)years .

Signature    the SUPPORTER
Date    

I   First Name   Last Name   (the Applicant), do hereby certify and attest that all information on this page is true and accurate. and that I am now living at the address provided by my 'Supporter'. I understand that if I become a patient with Sinclair Health Clinic, I will be required to immediately notify the Clinic of any change to my housing status.

Signature   the APPLICANT
Date   

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I   First Name   Last Name, certify that I am homeless. I have no physical address. I primarily reside in Winchester City, Frederick County, or Clarke County Virginia. I will tell Sinclair Health Clinic when my situation changes.

Signature   
Date       

I   First Name   Last Name, do hereby certify that all the above income information for the past 3 months is true and correct.

Signature   
Date   

I,   First Name   Last Name  , certify that I do not receive income from any of the following sources: 

• Wages from employment (including commissions, tips, bonuses, etc.);  
• Rental income from real or personal property;  
• Interest or dividends from assets;  
• Social Security payments, such as Supplemental Security Income, Social Security Disability Income, Retirement, Survivor’s Benefits, annuities, insurance policies, pensions, or death benefits;  
• Unemployment
• Periodic allowances such as alimony, child support.  

Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge.

Signature   

Date   

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I   First Name   Last Name (spouse/legal partner), do hereby certify that all the above income information for the past 3 months is true and correct.

Signature   Spouse/Legal Partner
Date   

I,   First Name   Last Name  (SPOUSE/Legal Partner), certify that I do not receive income from any of the following sources: 

• Wages from employment (including commissions, tips, bonuses, etc.);  
• Rental income from real or personal property;  
• Interest or dividends from assets;  
• Social Security payments, such as Supplemental Security Income, Social Security Disability Income, Retirement, Survivor’s Benefits, annuities, insurance policies, pensions, or death benefits;  
• Unemployment
• Periodic allowances such as alimony, child support.  

Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge.

Signature   SPOUSE/Legal Partner

Date   

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I   First Name   Last Name (dependant), do hereby certify that all the above income information for the past 3 months is true and correct.

Signature   Dependant
Date   

I   First Name   Last Name (dependant), do hereby certify that all the above income information for the past 3 months is true and correct.

Signature   Dependant
Date