Statement of No Income
This form is to attest to information in support of your application. Please answer all the questions below.
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Patient First & Last Name *
As a client of the Amity Medical Group, I testify that I receive no verifiable income of any kind. My current work status, disability, etc., affords me no income at this time and has not since (Please type date below) *
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Some types of help/assistance that I receive from others, with the exception of my basic needs (food, clothing or shelter), might be considered to be “in-kind” income. Please select one of the options below.
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If you DO RECEIVE IN-KIND INCOME, please list the type and the period of time “in-kind” assistance received (e.g.; cigarettes, rent/utility assistance, insurance assistance, etc.).
To the best of my knowledge, I understand all the  information provided in this form to be correct and true. (Please type your first & last name below as an e-Signature) *
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