The applicant shall submit the following as part of the application process, before any financial assistance is provided:

1. (a) A CIP application including:

   1. (1) The applicant’s dated signature, authorizing the release of information and allowing the department to communicate with health care providers; and
   2. (2) The applicant’s dated signature, authorizing the department to collect the applicant’s medical records;
2. (b) A signed statement verifying that the income information provided on the application in (a) above is correct; and

3. (c) Written documentation justifying the income information provided on the application form are correct, including:

   1. (1) The most recent income tax return of all those persons whose income is counted in determining family income;
   2. (2) The applicant’s 4 most recent consecutive paycheck stubs, if tax returns are unavailable; or
   3. (3) A letter from the applicant’s most recent employer indicating present gross salary or wages and expected changes during the next 12 months.

Source. #2484, eff 9-26-83; ss by #4167, eff 11-6-86; ss by #4638, eff 6-26-89, EXPIRED: 6-26-95 New. #8864, eff 4-13-07