Zero Income Attestation

This form is and attestation of Zero Income for Rural health Care, Inc's (RHCI) sliding Fee Program application and must be completed by any household member over the age of 18 claiming zero income.

Name

First Name Last Name

I attest that I am currently unemployed and:

I do not receive unemployment compensation or other benefits as a result of non-employed status I do not receive benefits or income from any other source example: (social security, disability, retirement, child support, rental, farm, alimony, interest and/or dividends, etc)

Any applicant claiming zero income must sign a Zero Income Attestation. This is a legally binding document in which false statements constitute fraud. By signing this attestation, the applicant or member of household gives RHCI permission to access the Internal Revenue Service for the latest federal income tax return.

Name on Application (if different than the name above)

I attest that the information given above is true to the best of my knowledge and that any misrepresentation of information will lead to termination and/or rejection of my application.

Signature

Clear

*If you have a change in income, please notify RHCI immediately

ZERO INCOME ATTESTATION