Attachment "C" If required by Advisor - print the Self-Attestation form, complete and submit. Applicant Name:
Last___________________________________ First _________________________________ MI _____
Social Security Number: __________ - ________ - ___________________ Date: ___________________
I hereby certify, under penalty of perjury, that the following information is true:
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I attest that the information stated above is true and accurate, and understand that the above information,
if misrepresented, or incomplete, may be grounds for immediate termination and/or penalties as specified by law.
Applicant's Signature Date
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Applicant's Phone Number
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Applicant's Address
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Signature of Parent or Guardian (as needed)
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The above applicant self-attestation statement is being utilized for documentation of the following eligibility criteria:
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Eligibility Intake Staff Person Name
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Signature Date
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