No Income Statement

No Income Statement
Client's Name*

First NameLast Name
Client Date of Birth*

MonthDayYear
Date
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.
If you are not receiving income at this time--please explain how you are paying for housing, utilities, medical expenses, food, and other expenses. *
By signing below I acknowledge that this information is true.

Clear
Signature date*

MonthDayYear
Date
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.
Witness Name*

First NameLast Name
Witness Phone Number*
Please enter a valid phone number.
Should be Empty: