I certify that the statements regarding the persons and income in my household are true and correct to the best of my knowledge.
I further understand if any information is found to be inaccurate, I may be denied a discount and/or subject to legal action for knowingly providing false information.
I agree to notify Inside Health Institute of all changes in income, address, living arrangements, number of household members, and/or other circumstances.
I understand that the information given above will be kept confidential.
I also understand that if I do not agree with any decision made concerning this application, I have the right to ask in writing for a review by the Executive Director.