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 SUPPORTERDate
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 APPLICANTDate After this page has been completed, please click NEXT to continue.
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:
Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge.
Signature
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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 PartnerDate
I, First Name Last Name (SPOUSE/Legal Partner), certify that I do not receive income from any of the following sources:
Signature SPOUSE/Legal Partner
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 DependantDate
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