Non-Relative Supporting Statement

Non-Relative Supporting Statement

Please provide the following information regarding the household.
Client's Full Name:*

First NameLast Name
Client's Date of Birth:*
Client: Please have a friend or neighbor complete this form. This person should not be a relative or any of your household members. This form is used to check your residency and household composition, which are requirements for eligibility.

To The Person Completing This Form: The client has applied for assistance. In order for DHS to determine eligibility, we need a statement from a person who is not a relative, not living in the household and who knows the applicant and household circumstances. Please answer the following questions to the best of your ability.
Client's Address:

Street Address

CityState / ProvincePostal / Zip Code
Names of adults living in the home:*
Names of children living in the home:*
How do you know that all these persons are living in the home?*
Your Full Name

First NameLast Name
Your Signature:*

Clear
Date:*

MonthDayYear
Date
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Should be Empty: