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Please complete this form and upload any requested documentation.  By submitting this form, you are sending this form securely to The Aliveness Project.  We request this information every six months as requested by our funding sources. If more information is needed, we will contact you. If you have any questions, please call us at 612.822.7946 or email zay@aliveness.org.

NOTE: You will not be denied any services even if your income exceeds guidelines.  Our services are available to anyone living with HIV/AIDS.  We must collect this information as a requirement of government grants we received for specific programs.
Demographics






Income Statement



Medical Information Update
Required for Federal Funding




Housing Status

E-Signature
By providing my electronic signature, I understand that this serves as a signature of certification that the above information is true and correct.  I understand that this information will be submitted to The Aliveness Project as updated information needed for funding purposes and will remain secure, private information.  If the above information changes, I will notify The Aliveness Project and provide updated documentation as needed.