Room of Board Statement 
For use with Medicaid applications
Applicant Name
Case Number
Date
Date of Birth
Home Address
Mailing Address
Phone Number
Email
This form is used to verify that the applicant/client resides at the address listed and receives room 
and board. Complete all applicable fields, including dates of residency and other occupants. Attach 
a utility bill in the property owner’s name, lease agreement, or other proof of residency.  Once 
completed, the form should be signed by the landlord (or property owner) and client, and submitted 
to the Medicaid office by walk-in, email, or mail, with the required documentation.  
Residency Verification (to be completed by the landlord or homeowner): 
I,  
 , hereby verify that  
 , is residing in my 
house/apartment located at  
.
Other occupants at this residence are:
1.  
	
Relationship:  
2.  
	
Relationship:  
3.  
	
Relationship:  
4.  
	
Relationship:  
5.  
	
Relationship:  
6.  
	
Relationship:  
Move in Date:  
 
Move-out Date (if applicable):   
	
	
Rent/Board Amount (if applicable): $  
or other  
Weekly
Bi-weekly
Monthly
Client Signature
Date
Client Printed Name
OR
Disclaimer: We do not discriminate on the basis of race, ethnicity, color, national origin, religion, sex, age, or disability. Free language assistance 
services are available for people whose primary language is not English. We also provide free aids and services to assist with communicating the 
information effectively (such as interpreters, captioning, Braille, or large print). If you need these services, please contact us by phone or email.  
St Thomas/St. John District: 340-774-0930 ext. 4104 or sttjmap@dhs.vi.gov | St. Croix: 340-772-7100 or stxmap@dhs.vi.gov 
Privacy Notice: The information provided on this form will be used only for purposes of determining and verifying Medicaid eligibility.                                         
Your information is protected under state and federal privacy laws. 
FOR OFFICE USE ONLY
Received by: 
 	
	
	
Date: 
Authorized Representative Signature
Authorized Representative Name
Phone Number
Email
Date
I,  
  certify under penalty of perjury that the information I have provided 
regarding the above-named applicant’s residence is true and correct to the best of my knowledge.  
Client Perjury Statement: 
Under penalty of perjury, I certify that the information presented in this document is true and accurate to 
the best of my knowledge. By signing below, I understand that providing false statements may result in 
termination, denial, or recovery of benefits.
Landlord/Property Owner Signature
Phone Number
Email
Date
Mailing Address
SIGN
SIGN
SIGN
SIGN