For documentation and verification purposes client is required to sign a self-declaration of no income form. Chore staff will mail client the form.
This person has applied for assistance with basic essential needs in their home to help continue living independently. Our funding through the City of Bellingham requires the Volunteer Chore Program to verify a disability for anyone under the age of 60 applying for services.
We ask for your cooperation in providing the following information and returning it to the person listed at the top of the page. Your prompt return of this information will help to ensure timely processing of the application for assistance. The applicant has consented to this release of information as shown below.
CLIENT RELEASE: I hereby authorize the release of the requested information. Information obtained under this consent is limited to information that is no older than 12 months. There are circumstances that would require the owner to verify information that is up to 5 years old, which would be authorized by me on a separate consent attached to a copy of this consent.
For each numbered item below select the option that accurately describes the person listed above.
1. Has a disability, as defined in 42 U.S.C. 423, which means;
2. Has a physical, mental, or emotional impairment that:
3. Has a developmental disability as defined in Section 102(7) of the Developmental
Disabilities Assistance and Bill of Rights Act 42 U.S.C. 6001 (8), i.e., a person with a severe chronic disability that:
4. Is experiencing a temporary physical or mental impairment that is affecting their ability to perform basic essential tasks that are critical to maintaining their independence. If so, what is the expected duration?