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Please return the completed form. By Mail:PO Box 1106 MS:LD2NLewiston, ID 83501 By Fax:1 (877) 3693407Asuris Northwest Health 528 East Spokane Falls Boulevard Suite 301 Spokane, WA 99202Affidavit
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01
Obtain the affidavit form for qualifying incapacitated dependent individual.
02
Fill in your personal information including your name, address, and contact information.
03
Provide details about the dependent individual who is incapacitated, including their name and relationship to you.
04
Describe the nature of the incapacitation and provide any supporting documentation if required.
05
Sign and date the affidavit in the presence of a notary public or other authorized individual.
06
Submit the completed affidavit to the appropriate organization or agency as instructed.

Who needs affidavit-of-qualifying-incapacitated-dependent-individual?

01
Individuals who have a dependent family member that is incapacitated and require proof of their status for legal or financial purposes.
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An affidavit of qualifying incapacitated dependent individual is a legal document that certifies the status of an individual who is dependent on another person due to incapacity, providing necessary information for legal or financial purposes.
Typically, the primary caregiver or the legal guardian of the incapacitated dependent individual is required to file the affidavit.
To fill out the affidavit, provide the personal details of both the dependent individual and the filer, confirm the nature of incapacity, and include any required supporting documentation along with signatures.
The purpose of the affidavit is to formally document the dependent's incapacity for eligibility in various programs or benefits, ensuring that the dependent receives appropriate support.
Information required includes the name, address, and date of birth of both the dependent and the filer, details of the incapacity, and any relevant medical or legal data.
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