Please complete the information below only if you have no other way to document your income. All information below must be answered. Failure to complete this form may result in denial of your Sliding Fee Scale application.
I First Name* Last Name* declare that I have been working and receiving payment doing * in the amount of $ Number* per day, week, bi-weekly, or month( select one* ).
I do not have check stubs or any other documentation, and it is NOT possible to have the people who have paid me to write a letter to prove my earnings.
I certify that I have no other way to document my income and that all of the above
information is true and correct. I understand that this information will be used to
determine my eligibility for a Sliding Scale Discount.