Fillable Self-sufficient-minor-status Self Sufficient minor Status

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Self-sufficient-minor-status Self Sufficient minor Status

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DOCUMENTATION OF SELF-SUFFICIENT MINOR STATUS
For the purposes of obtaining medical diagnosis or treatment, pursuant to Family Code
Section 6922, I hereby certify that the following is true and correct:
I am 15 years of age or older, having been born on (Date of Birth), in
________________ (City/State).
I am living separate and apart from my parents or legal guardian.
Current Address:
I am managing my own financial affairs.
_______________________________
(Source of income)
----------------------------------------------
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Self-sufficient-minor-status Self Sufficient minor Status

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Completed 11 March 2020

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