Green Form- Eligibility Verification

VERIFICATION OF ELIGIBILITY FOR STATE OR LOCAL PUBLIC BENEFIT

REQUIRED BY INDIANA CODE 12-32-1

Washington Township

Hendricks County

311 Production Drive

Avon, IN 46123

Phone: (317) 272-1835

Trustee

Don Hodson

Township Board

Steven Blacketer

Amanda Babinec

Shane Sommers

I, ___________ (Print Name Below), am a United States citizen or qualified alian (as defined under code U.S.C 1641)

I hereby verify under the penalty of perjury that the foregoing statement is true.

Dated This

Signature

Use your mouse or finger to draw your signature above

Print Name

Use your mouse or finger to draw your signature above