Vision Outreach Community Clinic Voucher Application

This application is for Berrien and Van Buren County residents in need of eye care assistance.

CLIENT INFORMAITON

Name (First, Middle, Last)

SPOUSE / PARTNER INFORMATION

Name (First, Middle, Last)

HOUSEHOLD EXPENSES

List the monthly cost of each of the following items.


I understand that the information which I submitted is subject to verification and review by by Federal and/or State enforcement agencies and others as required. I understand that a credit report may be requested and reviewed as required. I certify that the above information is true and correct.

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