Shared Housing Verification Form - English Spanish Combined 08
Shared Housing Verification Form - English Spanish Combined 08
Shared Housing Verification Form - English Spanish Combined 08
Applicant Declaration – The applicant’s household shares the same address with one or more households for economic reasons.
Each household must have separate income and/or means of support. The households share the occupancy costs but otherwise
are separate. Once verified, the applicant is permitted to declare shared but separate household to be considered for the
applicant’s eligibility determination for Sliding Fee Discount Program.
Part III To be completed by the person sharing household expenses with the applicant. If more than two households share
the same address, at least one person must disclose the amount(s) paid by the applicant.
I understand Greater Prince William Community Health Center may contact me to verify this information. Furthermore, I
understand providing false information or information subsequently determined to be false will result in the applicant’s eligibility for
SFDP discounts to be revoked and the full balance of the account(s) restored and payable immediately.
_____ ________________
Name (Please print) Signature Date
Effective: Imediately
Approved Date: 04/29/2015
Greater Prince William Community Health Center
4379 Ridgewood Center Dr, Suite 102, Woodbridge, VA 22192
9705 Liberia Ave, Suite 201, Manassas, VA 22010
17739 Main Street, Suite 130, Dumfries, VA 22026
Phone: 703.680.7950 Fax: 703.680.7953
Parte I Para ser completada por el aplicante Part II Para ser completada por el aplicante
Parte III Para ser completada por la persona que comparte gastos del hogar con el aplicante. Si dos ó más familias comparten la
misma dirección, al menos una persona debe revelar la cantidad pagada por el aplicante.
Tengo entendido que Greater Prince William Community Health Center puede ponerse en contacto conmigo para verificar esta
información. Además, entiendo que proporcionar información falsa, entiendo el suministro de informacion falsa o que
posteriormente determinada que era falsa dara lugar a la elegibilidad del solicitante para el Programa de Escala de Descuento
pueda ser revocada y el saldo total de las cuentas restauradas y pagos seran requeridos inmediatamente.