Fillable Printable KSFHP Self-Declaration Form Employment and Income - Kansas

KSFHP Self-Declaration Form Employment and Income - Kansas

KSFHP Self-Declaration Form

Employment and Income

KSFHP 2014

Patient Information

Client’s Name:

Client’s D.O.B:

Address: Phone Number:

Declaration of Employment:

This section is to be fille d out and signed by the employed individual

I _______________________________________________ declare that my principal

employment is or was in agriculture and that presently: [ ] I am working [ ] I am not working

Employer Name:________________________________________________________

Employer Address:______________________________________________________

Declaration of Income and Family size:

I declare that my household [ ] weekly [ ] biweekly [ ] monthly [ ] annual income was

$_________________. I also certify that a total of ___________ people (including spouse,

children, parents, grandparents, etc.) are living in my household and supported by this income.

I certify that the information that I provided is correct and I authorize Kansas Statewide

Farmworker Health Program to use it. I understand that this information will be used to

determine my eligibility for a Sliding Scale Disco unt for health services.

Applicant Signature:_________________________________ Date:_________________

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