I/We certify the following:

1.) that I/we fall within the "Low-to-Moderate" income bracket.

2.) that I/we have little or no medical coverage

3.) that I/we have provided all information to the best of my/our knowledge

4.) that I/we suffer from life-threatening illness(es) that require medication

5.) that I/we are 50 years of age or older

Signature (Applicant's Name):     

Date:     

Signature (2nd Applicant - if applicable):

Date: