Self Employed or Undocumented Income

Self Employed or Undocumented Income
Minority Health Consortium (MHC)

Client Self-Employment or Undocumented Income Attestation Form

*For Use with Ryan White Part B Eligibility Determination*
Client Full Name
Date of Birth

MonthDayYear
Date
Address
Phone Number

Area CodePhone Number
Date of Attestation

MonthDayYear
Date
INCOME DECLARATION
The undersigned, hereby affirm I currently have no verifiable income due to:
If applicable, please provide a brief description of the nature of your work including services provided and income sources:
Estimated Monthly Income: $
*Note: This information is required to determine eligibility for Ryan White services and will be kept confidential in accordance with federal and state regulations.*
CLIENT ATTESTATION
I certify that the above information regarding my income is true and accurate to the best of my knowledge. I understand that this form is used to determine my eligibility for services under the Ryan White Part B Program. I understand that providing false information may result in denial or termination of services and could be subject to legal consequences.
Client Signature
Date

MonthDayYear
Date
STAFF USE ONLY
Type of confirmation: (check all that apply)
Based on the information provided, the client's income has been assessed for eligibility purposes in accordance with Ryan White Part B Program standards.Client's Federal Poverty Level (FPL) Percentage:
Eligible for Ryan White Services:
Staff Name:
Staff Name:
Staff Title
Staff Signature
Date

MonthDayYear
Date
Should be Empty:

Self Employed or Undocumented Income

INCOME DECLARATION

CLIENT ATTESTATION

STAFF USE ONLY