JPS Health Network Verification of Assistance and Residency for JPS Connection Program at a glance
What it is: The JPS Health Network Verification of Assistance and Residency for JPS Connection Program form only needs to be completed if the applicant is being supported by another individual.
Notary: This form must be signed and notarized.
A filled-in JPS Health Network Verification of Assistance and Residency for JPS Connection Program example: an aunt verifies her nephew's residence
How to fill out JPS Health Network Verification of Assistance and Residency for JPS Connection Program, box by box
Name of person providing assistance
After I, write the Name of person providing assistance; after verify that, the Applicant's full name and the Patient's MR# and/or Social Security #; after lives at, the Applicant Address and City/Zip Code.
Financial Assistance
Under Financial Assistance, mark Yes or No for: I provide financial assistance to the applicant; This individual is claimed as a dependent on my most recent filed income tax return.
Does the applicant have a job? Write Yes or No and, if yes, provide employer name. Does the applicant have another income source? Write Yes or No and, if yes, how much.
I provide applicant with the following
Mark what you provide the applicant with: Food, Personal items, Transportation, Cash/Check $ per Week or Month, or Other.
Do you pay rent or other bills for this applicant?
Do you pay rent or other bills for this applicant? Write Yes or No and, if yes, how much and how often?
Residency Assistance
Under Residency Assistance, mark The applicant resides at my Tarrant County residence. Then mark They do not pay me rent, or mark They pay and write what they pay to help toward the rent and utilities.
Write how long the applicant has lived at your Tarrant County residence. Does the applicant have another residence? Write Yes or No and, if yes, where.
Documentation Attached for Person Providing the Assistance
Under Documentation Attached for Person Providing the Assistance, mark Provide picture identification (example - Drivers License) and Provide proof of residence (example - utility bill, lease agreement or ownership documentation).
Relationship to Patient
Write the Relationship to Patient.
Signing and notarizing the form
You certify that the information is true and correct. Everything on this application is the truth as best you know it.
Anyone who knowingly lies or misrepresents the truth or arranges for someone to knowingly lie or misrepresent the truth in the completion of this application is committing a crime which can be punished under federal law and/or state law.
Write the Signature - Person providing assistance, the Address, City, State, Zip, the Phone Number and the Date signed.
Under State of Texas County of, a notary public writes the County, the name of the person who personally appeared and signs on the Notary Public's Signature (Personalized Seal) line.
Sources
[1] JPS Health Network Verification of Assistance and Residency for JPS Connection Program (no printed edition), served file (the Official source link on this page).
