Dear ___________________________,
GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS DEPARTMENT OF HUMAN SERVICES _________________________________________________________________ VI STATE PHARMACEUTICAL ASSISTANCE PROGRAM INCOME INFORMATION Date___________________________ I.D. NUMBER__________________ NAME OF CLIENT _____________________________________________________ INCOME INFORMATION: Wages/Salary/ Tips $___________________________________ Profit from Self Employment $ ___________________________ Interest from Savings Accounts $ _________________________ Interest from Certificates of Deposits (CD’S) $ ______________ Other Interest Income and Dividends ______________________ Pair Market Rental $ ________________________________ Other In-kind Income $______________________________ _______________________________ _______________________________ Rental Income $ _______________________________ Unemployment Insurance $_____________________ Workmen’s Compensation $_____________________ Veteran’s Compensation $_____________________ Social Security $_____________________ Pensions, Annuities & Private Insurance $ ____________ …
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GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS DEPARTMENT OF HUMAN SERVICES _________________________________________________________________ VI STATE PHARMACEUTICAL ASSISTANCE PROGRAM INCOME INFORMATION Date___________________________ I.D. NUMBER__________________ NAME OF CLIENT _____________________________________________________ INCOME INFORMATION: Wages/Salary/ Tips $___________________________________ Profit from Self Employment $ ___________________________ Interest from Savings Accounts $ _________________________ Interest from Certificates of Deposits (CD’S) $ ______________ Other Interest Income and Dividends ______________________ Pair Market Rental $ ________________________________ Other In-kind Income $______________________________ _______________________________ _______________________________ Rental Income $ _______________________________ Unemployment Insurance $_____________________ Workmen’s Compensation $_____________________ Veteran’s Compensation $_____________________ Social Security $_____________________ Pensions, Annuities & Private Insurance $ ____________________________ ____________________________ ____________________________ ____________________________ TOTAL INCOME $ _________________________________ CIVIL RIGHTS CLAUSE: No person shall, on the grounds of race, color, sex or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under this program. Please be aware to recertify I certify that the information given is true and correct. Client’s Signature: ______________________________ Employee’s Signature____________________________ Director’s Signature _____________________________