HHSA - DSS - WTW 501 Self Attestation Form

Self Attestation Form
Case Number*
Enter “unknown” if you do not know
Name*

First NameLast Name
Email Address*
example@example.com
Check this box if you do not have an email address
Did you review all forms including the Employment Services Handbook?*

YesNo
Would you like an Employment Services Handbook mailed to you?*

YesNo
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Which of these are community partners may you receive a referral to?*

Western SierraConnecting PointTurning PointUnited Way
True of False: I only need to talk to my social worker when I need something?*

TrueFalse
Signature*
Date*

MonthDayYear
By signing and submitting this form, I am certifying that:

I have watched the Employment Services Welfare to Work orientationI have read the information located under Program OverviewI have read and understand my Rights and ResponsibilitiesI have viewed and/or downloaded or requested a copy of the Employment Services Handbook
HIDDEN

I have watched the Employment Services Welfare to Work orientationI have read the information located under Program OverviewI have read and understand my Rights and ResponsibilitiesI have viewed and/or downloaded or requested a copy of the Employment Services Handbook
Form: IMG 631
Should be Empty: