To whom it may concern,
I do hereby certify that I am currently receiving no income from any source. I understand that that by completing and signing this I am certifying that the information is true. I understand that falsifying this information will make me ineligible for any sliding fee or assistance. If at anytime this information and I have an income I will update my information with Ravenwood Health within 14 days.
Normally, this document requires the second signature of a witness to verify the information. Please provide the name and contact information below for a witness that could be called to verify this information if necessary. Thank you.