Hope Clinic Eligibility Verification Form Eligibility Verification Form Application Date: * Patient name: * First Middle Initial Last Name Patient Date of Birth: * What is your annual or monthly household income? To see if you quality, go to this link https://home.mycoverageplan.com/fpl.html * Is the above figure a monthly or annual income? * Monthly Annual Upload Proof of Income (Tax Form or last two paychecks) Drop a file here or click to upload Choose File Maximum upload size: 2.1MB Verify and Attest to your Household Size: * Verify and Attest to your Annual Household Income: * I understand and attest to the information below by my answers to those that apply: My income is less than or equal to the 300% Federal Poverty Guideline as indicated by the Federal Poverty Level Table in the link provided above. * Patient name (if minor, patient’s parent guardian name) * Patient signature (if minor, patient’s parent guardian signature) * Clear Date * reCAPTCHA Submit If you are human, leave this field blank.