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+ [PII]

Client name: Human Services Campus  Client ID# Canceled

v  I currently receive Social Security Income in the amount of $ E  per month. 

v  I currently receive Social Security Disability Income in the amount of $ F per month. 

v  I currently receive Other Income in the amount of $ G per month. 

I attest that my total family/household income is $ H (-)-p-e-r- -y-e-a-r-(-)- per month. 

This income supports I adults (including myself) and J children under age 18. 

X                               01/15/2018

Client's signature  Date

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