If you are not receiving income from any source, we require this form to be filled out 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the date at the top of the form. This helps establish when the form was completed.
3. Fill in your full name in the 'Patient Name' field, ensuring accuracy for identification purposes.
4. Provide your current address in the designated section to maintain up-to-date contact information.
5. Enter your Social Security Number (SSN) in the appropriate field; this is crucial for verification.
6. Indicate your last date of employment, which is necessary for assessing your financial situation.
7. In the statement section, confirm that you are not receiving any income by signing and dating where indicated.
8. If applicable, have an individual assisting you complete their section, including their signature and relationship to you.

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