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
I do not have an email address
Did you review all forms including the Employment Services Handbook?
Would you like an Employment Services Handbook mailed to you?
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Which of these are community partners may you receive a referral to?
True of False: I only need to talk to my social worker when I need something?
Signature
Signature*
Signature
Date

MonthDayYear
By signing and submitting this form, I am certifying that:
HIDDEN
Form: IMG 631
Should be Empty: