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Date of Referral: Individuals Name: DOB: Age: SSN: Is individual currently receiving care from VPH? Y N (If Y, please include CID#)Primary Language (Hispanic or other) Is individual aware of your
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How to fill out is individual currently receiving

01
The individual currently receiving needs to complete the required paperwork and provide necessary documents.
02
They should carefully read and understand the instructions for filling out the form.
03
They need to provide accurate and truthful information in all the sections of the form.
04
If any fields are not applicable, they should mark them as N/A or leave them blank as instructed.
05
They must sign and date the form at the designated place.
06
After filling out the form, they should review it to ensure all information is provided correctly.
07
They should submit the completed form along with any required supporting documents to the appropriate authority.

Who needs is individual currently receiving?

01
Any individual who is eligible and meets the criteria set by the program or organization offering the benefits.
02
These individuals may include low-income families, individuals with disabilities, students, unemployed individuals, or any other targeted group.
03
The specific eligibility requirements may vary depending on the program or organization.

What is Is individual currently receiving care from VPH Form?

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The individual is currently receiving income from their job.
The individual is required to file their own income received.
The individual can fill out their income information on government forms or online tax platforms.
The purpose is to report all income received for tax purposes.
All sources of income, including wages, bonuses, and investment income, must be reported.
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