Certification of Zero Income

Enter information on all members residing in your household. Please include their name, relationship to the client, date of birth, and income.
Please list name(s) and phone number(s) of person/ organization providing basic needs.

I certify that the information provided in this form is accurate and true. I understand that if I willfully withheld and/or gave false information on purpose for my gain, I may be dismissed as a patient of Lakeland Volunteers in Medicine. I also understand that Lakeland Volunteers in Medicine may verify any/all information provided on this form.

Please allow the client to type their name here.