ELIGIBILITY FORM Eligibility Attestation First & Last Name Date of Birth (mm/dd/yyyy) Email Phone Numer I hereby attest that my current estimated annual income from wages is Additional income sources such as social security disability income, workers compensation benefits, dividends, interest, assistance from family, friends or charity, public assistance and/or food stamps, or other sources: These additional sources of income are Income for all others living in my household during the same 12 month period: Number of individuals in household: Total income from wages and all other sources: I hereby attest that I am not covered by any form of prescription insurance, nor am I covered by any form of government-sponsored health insurance, including Medicare, Medicaid, VA benefits, or other coverage. (Y/N) Signature I certify that all of the above information is true and accurate. I understand that this information is to be used to determine eligibility for the Dispensary of Hope and its related access sites. I will notify staff of any changes in employment, income or insurance prior to having additional prescriptions filled. Fields required
