Statement of Last Employer

Statement of Last Employer
The last time that I was employed was *
My last employer was*
I certify that I currently have no income from employment including self- employment income.

I am signing this under penalty of perjury which means I have provided true answers to all the questions on this form to the best of my knowledge. I know that I may be subject to penalties under federal law if I provide false or untrue information. I know that I must tell the Department of Human Services (DHS) if anything changes (and is different than) what I declared on my application. I can call 1-855-372-1084 to report changes or contact a DHS county office. I understand that a change in my information could affect the eligibility for members of my household.
Name*

First NameLast Name
Address*
City*
State*
Zip Code*
County*
Social Security Number*
Social Security Number*
Date of Birth*

MonthDayYear
Date
Signature*

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Date

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Eaton Agency| 888-608-1541|FAX: 501-421-9970| www.eatonagencyllc.com| License# 6624853|
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