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Ramsell Public Health RX
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Support Verifi cation Affi davit
The following information is required for applicants who are being supported by another individuaVagency or are homeless,
and are unable to orovide oroof of income or residencv.
Applicant's Name: DANIEL
Applicant's Current 933 BEGONIA AVE
The following statement is to be completed by the person who is providing support to the applicant.
The individual named above receives the followins from me:
I expect to continue to provide these items until:
to the person named above is:
I certifu that the information in this section is true and correct.
Provider Name (print):
The following statement is to be completed by the agency representative who is able to verify the client's Iiving
or support situation.
The above named Derson
the followine services
from this asencv:
[ ]SocialServices [ ]Other:
I certi$r that the above
[ ] Homeless, but is a
Agency Narne (print):
named person is: [ ] Homeless with no source of income,
resident of CA, [ ] Other
Agency Representativ e (print) :
Agency Telephone Number: