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FL Immunization Screening Portal

Household Financial Declaration Questionnaire

Select Language

Select Service County*

Patient Information:

First Name*

Middle Name

Last Name *

Date of Birth *

Sex*

Email

Marital Status

Household Information:

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

Estimated Earned Monthly Income *

Unearned Monthly Income *

Unearned Monthly Income Include:

Social Security, Public Assistance, Unemployment, Alimony, Worker's Comp, Child Support, Other

Signature Date