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Environmental Health Phone: 703 I 777-0234 Fax: 703 / 771-5023 Loudoun County Health Department P.O. Box 7000 Leesburg,VA 20177-7000 FAMILY PLANNING ELIGIBILITY Community Health Phone: 703 /777-0236 Fax: 703 / 771-5393 ELIGIBLILllY DOCUMENTS WILL BE ACCEPTED ON WEDNESDAYS ONLY BETWEEN THE HOURS OF 9-11AM AND 1-3PM ON A FIRST COME FIRST SERVED BASIS Please complete the registration form in this packet and bring the following: IDENTIFICATION that has your picture PROOF OF ADDRESS with your name and your current address PROOF OF INCOME from all working members of your household You will need to provide ONE document from each of these categories PICTURE IDENTIFICATION • Driver's license • Passport • Foreign country ID • Green card • School ID PROOF OF ADDRESS • Driver's License • Utility Bill • Doctor's office bill • ID card with current address • Lease PROOF OF INCOME • Your last .3 consecutive pay stubs • Statement from employer • Income tax return only if self employed • Unemployment benefits letter • Benefits letter from social services • Child support statement **WE WILL NOT ACCEPT ELGIBILllY WALK-INS ANY OTHER DAY OF THE WEEK** ---PAGE BREAK--- ---PAGE BREAK---