Self-Attestation of Zero Income

As a Federally Qualified Health Center, St. George Medical Clinic, Inc. is required to verify the household income of patients accessing services. To comply with this requirement, we ask for your cooperation in supplying the information requested in the Attestation below. This information will be kept confidential and used only for the purpose of establishing your eligibility.

    I, , do hereby certify that I do NOT receive the following income from ANY source. I understand sources of income include, but are not limited to, the following:

    • Wages, salaries, and tips

    • Social Security benefits

    • Unemployment compensation

    • Self-employment or business income

    • Alimony

    • Retirement and pension income

    • Investment and rental income

    • Other Taxable Income

    Please explain below how you (or your family) have paid for these three living expenses when your household has had no income.

    Disclaimer and Signature

    I do hereby attest that this information is true, accurate, and complete to the best of my knowledge and I understand that any satisfaction, omission, or concealment of material fact may subject me to disqualification form the Sliding Fee Discount program.

    Our Main Clinic

    8591 Holly Meadows Road
    Parsons, WV 26287

    Phone: 304-478-3339
    Fax: 304-478-3311

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