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This SAMPLE intake form and instructions are provided as a resource for ERA1 and ERA2 HSS Subrecipients and not as a requirement. Subrecipients may use this form on or before May 10, 2023, for client
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How to fill out hss-intake-checklist-self-attestation-sample

01
Follow the instructions provided in the hss-intake-checklist-self-attestation-sample document.
02
Fill out each section of the checklist accurately and completely.
03
Make sure to sign and date the self-attestation section as required.
04
Review the completed checklist for any errors or missing information before submitting.

Who needs hss-intake-checklist-self-attestation-sample?

01
Individuals who are required to complete a self-attestation checklist as part of the intake process for a health and social services program.

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It is a form used to document self-attestation for HSS intake checklist requirements.
All individuals applying for HSS services are required to file this form.
The form should be completed by providing truthful answers to the questions listed on the checklist.
The purpose is to ensure that applicants meet the necessary requirements for HSS services.
Information related to eligibility criteria for HSS services.
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