Employer Income Attestation 
 	Name:  

 	

 	
 	 
 	Date of Birth: 

 	 
 	 
 	Dear Employer, 
 	The above-named individual identified you as a source of income for their household. In order to complete their enrollment in various assistance programs, we need verification of wages. 
 	Thank you for your assistance! 
 	White House Clinics 
 	 
 	1. Employer Name 

 	 

 	 

 	 

 	 
 	 
 	2. Amount of Employee’s Typical Paycheck 

 	 

 	 

 	 
 	 
 	3. How often do you pay the employee? 
 	Weekly 
 	Every Other Week 
 	Monthly 
 	Twice a Month 
 	Other (please explain) 

 	

 	

 	

 	 
 	Please read the following statement and sign below. 
 	I certify the above information is true and correct. I understand that this information will be used to determine eligibility for the patient assistance programs at White House Clinics.  
 	
 	Employer Signature 
 	
 	Internal Use Only (should be completed by WHC employee who completes financial statement with patient) I certify that I asked the applicant/recipient about all sources of income received by the household and, before using this form, used best efforts to obtain other possible sources of documentation. 

 	 

 	Employee Signature 
 	 
 	Printed Name of WHC Employee 
 	 
 	Date 
 	 
 	Employer Income Attestation 6/2018