Application for Sliding Scale Fee
Submit with proof of income such as:
recent paycheck stub
first page of most recent tax return
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Name
First Name
Last Name
Work Information
Full Time Work
Part Time Work
Full Time Student
Part Time Student
Not Employed
I have a church (or organization) sponsorship. Please include name and contact information of representative
Spouse and Family Information - please include name of spouse, occupation status and number of dependents
Please enter Adjusted Gross Income (pre-tax) of most recent tax return
Has your employment changed since your last tax return (if yes, please explain)
Has your household/family income changed since your last tax return? (if yes, explain)
Current Monthly Income: Personal & Spouse
Is there any additional information you'd like us to consider?
Signature
Date
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Month
-
Day
Year
Date
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