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• Citizenship status • Social Security number • Valid exception to applying for SSN (i.e., when client’s stated SSN is not verified by data match, or when proof of application or for SSN is not provided for an applicant/member who is not a newborn). • Legal documentation that includes but limited to trusts, wills, court orders, contracts and any referenced schedules, exhibits, or attachments to these documents. • Disability status • Waiver approvals • For assets held by an open financial institution, a written attestation may only be accepted if the applicant/member has attempted to gather the documentation but was unable to; and the applicant/member has signed the Authorization for Release of Financial Information (State Form 3234/ FI 0014) or Life Insurance Verification (State Form 4478/FI 0775) and returned the form to DFR, but the institution has not responded to DFR by the deadline
A written statement must be submitted to the DFR detailing what steps were taken to gather the required documents. The statement must include the applicant or member’s best estimate of the information that was requested (for example, an estimate of income received or when the income ended). The statement must be dated and signed by the applicant/recipient or authorized representative. All written and attested statements must include a signature, date, and give specific monetary/frequency terms of actual/anticipated projections of income and or resources when applicable. For example: My husband earns $500/month, or I have $50.00 in cash on hand. This information will need to be provided for applicants/household members. The worker must document the reason for the signed statement.
Examples of satisfactory written attestation:
Name: Janet Jones DOB: 01/01/1980 Address: 123 Main Street, Indianapolis, IN
I lost my job with ABC Company on March 1st of this year. I asked them to fill out a form or give me a letter about my job but they are not responding. Their phone number is 317-555- 1212.
My last pay from ABC Company was March 15th. I was paid every two weeks, and the check was for 60 hours at $10.00 an hour, for a total of $600 before taxes.
This is information is complete and correct to the best of my knowledge.
Signature
Date