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INCOME VERIFICATION AUTHORIZATION
Income Verification
Client's Name
D.O.B.
I Certify that the information provided is accurate for the purpose of verification of gfamily income. I understand that income is used to determine any applicable fees for service. I understand that I may be responsible for a co-payment for services based on a sliding fee scale. Failure to pay for services rendered may prevent me from receiving future services.
Please provide at least one of the following acceptable documents of income
*
IRS tax forms from most recent year available - Form 1040
W2 Forms
Copies of current payroll stubs for one month
Certifications of income from non-payroll sources such as
Unemployment
Disability Compensation
Worker's Compensation
Aid to families of Dependent Children (AFDC/WIC)
Supplemental Security Income (SSI)
Copies of Social Security earnings statements
Free/reduced lunch eligibility from Broward Schools
Please Check all that apply.
My child currently receives free/reduced lunch
I have more than one child with disabilities
I recently lost my job and I am currently unemployed
I have an immediate family member living in the home who is terminally ill
Parent is currently deployed by armed forces
Number of Family members, including parent(s) and children living in the home
My Name below indicates that I have read and understood and agree to comply with the program guidelines and requirements. It is my understanding that my failure to do so may result in service(s) being terminated. I agree to pay any co-pay fees that may apply.
Signed
*
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Hire an Advocate
Income Verification
Authorization Release
Contact
Our Mission
Board of Directors
Araceli Barriga
Jessica Delano
Marshal I. Solis
Faustino Alvarez
Michelle Ortega
Secret IEP Guide
Directory
Categories
Add your Listing
Login
Events
Donate
Store
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