Orange County NC Website
Browse       Search
Board of Health P&P Manual, Section I <br /> Policy E,Attachment A <br /> VERIFICATION OF INCOME AND/OR RESIDENCY <br /> To Whom It May Concern: <br /> The Orange County Health Department is trying to determine the eligibility of <br /> for services requested at our agency. <br /> INCOME ( Check if required to provide) <br /> It is our policy to charge fees based on the income and household size. The above named person <br /> reports that he/she and his/her family has no income and does not receive Medicaid or public <br /> assistance. <br /> reports that he/she receives financial support from you. Please <br /> verify below the amount of monthly support that you currently give to this person and sign your <br /> name at the bottom of the form. <br /> $ per (check) _week _bi-weekly _month <br /> RESIDENCY Check if required to provide) <br /> reports that he/she and his/her family live at the address listed <br /> below. Before we can determine eligibility,we need a third party to confirm this information. By <br /> signing this form, you are saying that, to the best of your knowledge, this person/family lives at this <br /> address in County. <br /> Street/Apt City State Zip <br /> Sign Your Name Date <br /> Print Your Name <br /> Thank you for this information. This will help us determine how we can best serve this person. <br /> Office Assistant Signature Date <br /> Interpreter Signature Date <br /> S:\MANAGERS WORKING FILES\BOH\Policies and Procedures\BOH Policy Manual\Current Policy Manual\I.E. <br /> Attachment A-Income&Resid Verification.docx <br /> Updated 11/2014 <br /> 919 245 2400 ) 300 West Tryon Street ) Hillsborough, NC 27278 ) orangecountync.gov <br />