SpectraPlan Income Verification

SpectraPlan Income Verification

Spectra Health Clinics
Patient Name:

First NameMiddle Initial (Not Required)Last Name
Date of Birth

MonthDayYear
Phone Number
Format: (000) 000-0000.
- Employment Income
  - most recent federal income tax return
  - most recent consecutive pay stubs, for two pay periods
  - a letter from employer validating hours & wages
  Immigration Income
  - Immigration form I20 or J1
  - proof of Refugee Cash Assistance
  Self-Employment
  - current income statement
  - most recent federal income tax return
  Public Assistance (TANF, MFIP)
  - current year award letter(s) listing amount received
  Social Security Benefits
  - current year award letter(s) listing amount received
  Unemployment Compensation
  - current year benefit award letter
  Workers' Compensation
  - current year benefit award letter
  Retirement/Pension
  - Plan administrator documentation stating current year's monthly benefit amount
  No Income
  - Letter from previous employer documenting final day of employment
  - Letter from a case worker, on agency's official letterhead
  - Tax Form 4506-T (Request for Transcript of Tax Return)
- Please upload your proof of income here:
  
  Cancelof
- If you have any questions about this form, or the SpectraPlan, please feel free to contact Social Services at:
  
  socialservices@spectrahealth.org
  
  or
  
  701-757-2100 ext. 1218
- sender email
  example@example.com
- form sender
- Should be Empty: