Statement of Housing and Financial Status

Statement of Housing and Financial Status
This form is designed to help us better understand your current living arrangement and financial circumstances so we can provide appropriate support and resources. Please answer the questions as accurately as possible, and if your situation changes, we encourage you to update us.
Patient Information
VIM Membership ID
Name

First NameLast Name
Date of Birth

MonthDayYear
Current Housing Arrangement

I attest that I do not have a stable or independent living arrangement and may not have documentation proving my current residence. My situation includes one of the following:
I am currently homeless and do not have a fixed, regular, or adequate nighttime residence.I am staying temporarily with family members or friends and am not responsible for paying rent, utilities, or other costs associated with the upkeep of the home.I am living with a partner or individual who is fully supporting my housing and household expenses, including rent, utilities, and maintenance.Other
Additional Comments:
Current Financial Situation

I attest that I am facing challenges in managing my living expenses. My situation includes one of the following:
My income is zero or too low to reliably cover rent, utilities, and basic needs.I am temporarily relying on savings or credit to cover essential expenses but do not have a sustainable source of income.I am financially dependent on others for housing, food, or essential expenses.Other
Supporter Name:
Phone Number
Please enter a valid phone number.
Additional Comments:
I understand that I must report any change in housing and/or income status to Volunteers in Medicine Clinic Hilton Head Island.

By my signature below, I attest that the information provided is accurate, complete, and true to the best of my knowledge and belief. I acknowledge that any omission or inaccurate information could jeopardize my request for assistance.
Signature

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Today's Date

MonthDayYear
Date
Should be Empty:

Statement of Housing and Financial Status

Patient Information

Current Housing Arrangement

Current Financial Situation