Client Eligibility Assessment Form

CLIENT ELIGIBILITY ASSESSMENT FORM

RECITALS

WHEREAS Provider Name: provides intake, eligibility assessment, and related administrative services for prospective clients;

WHEREAS Client Name: requests assessment to determine eligibility for the Provider's programs, and consents to information collection and evaluation under the terms set forth below;

WHEREAS the parties intend that the assessment results and any agreement arising from this assessment be reduced to writing and governed by this form;

CLIENT INFORMATION

ELIGIBILITY CRITERIA

Evaluate the following criteria. Check applicable items and provide documentation where indicated.

FINANCIAL AND HOUSEHOLD INFORMATION

SCOPE OF WORK / ASSESSMENT

The Provider shall perform the eligibility assessment services described below. The assessment includes document review, interviews, verification of stated facts, and a written determination of eligibility status.

PAYMENT TERMS

The Client agrees to pay the Provider for assessment services in accordance with the terms set forth below. All amounts are due in U.S. dollars unless otherwise specified.

Unless otherwise agreed in writing, payments not received within the agreed period shall incur the stated late fee and may result in suspension of services until accounts are brought current. The Client remains liable for all costs of collection, including reasonable attorney fees.

TERM AND TERMINATION

This assessment engagement begins on Start Date: and, unless earlier terminated, ends on End Date: .

Either party may terminate this engagement for convenience upon written notice to the other party delivered not less than Notice Period (days): days prior to the effective termination date. Termination does not relieve the Client of obligations to pay for services performed prior to termination.

CONFIDENTIALITY

The Provider shall maintain as confidential all non-public information obtained from the Client in the course of the assessment and shall not disclose such information except as required by law, with the Client's prior written consent, or to subcontractors bound by similar confidentiality obligations. Confidential information does not include information that is or becomes publicly available through no breach of this agreement.

GOVERNING LAW

This form and any dispute arising out of or related to it shall be governed by and construed in accordance with the laws of the State or jurisdiction selected by the Provider: , without regard to conflict of laws principles.

ENTIRE AGREEMENT

This form, together with any attachments or documents expressly incorporated herein, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, representations, and understandings, whether written or oral. Any modification must be made in writing and signed by both parties.

ASSESSMENT FINDINGS (TO BE COMPLETED BY PROVIDER)

CERTIFICATION

By signing below, the Client certifies under penalty of perjury that the information provided in this form is true, complete, and accurate to the best of the Client's knowledge. The Client authorizes the Provider to verify any information submitted and to obtain records as reasonably necessary to complete the assessment.

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