HCV Personal Declaration Packet

Page 1 of 8

WARNING!! TITLE 18, SECTION 1001 OF THE U.S. CODE STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES.

 

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Head of Household

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Statement of Household Size

Please list ALL Persons who reside in your household (including yourself).  You must use the correct legal name for each member as it appears on their Social Security card.

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Household Information

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Note: ALL adults claiming ZERO income MUST complete a notarized statement of zero income.

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Statement of Assets

You must select YES or NO for each Question

ASSETS

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PROPERTY

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Statement of Eligible Expenses

You must select YES or NO for each Question

CHILD CARE EXPENSES

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CARE ATTENDANT / MEDICAL EQUIPMENT EXPENSES

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MEDICAL EXPENSES

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CERTIFICATION / ACKNOWLEDGEMENT

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Statement of Household Income

All Adult household members MUST complete a Statement of Income.  Please repeat this form for each Adult household member.

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NOTE:  Please only click Submit ONE TIME.   It may take up to 30 seconds for the file to be submitted.