Sliding Fee Discount Program Application
Please complete the following form to apply for the sliding fee discount program.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Have you already scheduled an appointment?
*
Yes
No
When is your appointment?
*
Necessary Documents
The below is a general list of items that you may need during the application process. If you are unsure whether or not an item applies to your application, please call a financial counselor by calling 317-291-7422. You can upload the documents in advance of your appointment using this page.
ID Verification
Valid state-issued or Foreign photo operator's license or ID card
Valid US or Foreign Passport
I will bring this to my appointment
ID Verification Upload
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Proof of Residence
Mortgage or Current lease
Utility bill within last 30 days
Current homeless shelter residency verification
Proof of Residence Upload
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Proof of Income
Proof of income 5 most recent pay stubs or statement from employer on Company or Shalom letterhead with current gross income.
Past years' annual tax returns (Self-employed only)
Social Security or SSI/SSDI award letter (Call 1.800.772.1213 for replacement)
Verification of pension or retirement benefits
Proof of Income Upload
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Proof of Unemployment
Current statement from INET (WorkOne) if unemployed
Statement of support of person(s) providing room and board with his/her name, address and what is being provided.
Current trustee assistance - poor relief award letter
Proof of Unemployment Upload
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Family Composition
Proof of dependent (s) birth certificate (s)
Verification of enrollment for 18 and older student
Tax records with dependent (s) listed
Court-ordered guardianship or custody papers
Divorce decree
If spouse has moved out of the home, proof of spouses current address
Family Composition Upload
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Other Documents
Copy of Medicaid/HIP award or denial letter
Verification of HPE/PE application (if applicable)
Proof of Medicare (including Part D) coverage
Public Assistance (Excludes Food Stamps and Housing subsidies)
Child Support
Last three months of complete bank statements for all accounts
Verification of student loans or grants (Proof of student enrollment)
Verification of any other income
Other Documents Upload
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