KENTUCKY CARE COORDINATOR PROGRAM
A Program of the Kentucky Department of Public Health
Statement of No Income
I _____________________________, declare that I currently have zero income.
I am meeting my daily living needs by:
In the future, should I receive income, either through employment, Supplemental
Security Income (SSI), Social Security Disability, or other means, I understand
that I must notify my Care Coordinator immediately. Also, I understand I will be
notified by my Care Coordinator or staff from the KCCP if changes in my income
affect my eligibility in the Program.
Client Signature: ________________________________________________________
Date ___________________________________
Witness (if client is unable to sign) __________________________________________