OHL Sliding Scale Form

Open Heart Leaders Sliding Scale Form
First Name*
Middle
Last*
Other names
Date of Birth*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Home Address*

Home Address

Street Address Line 2

CityState

Zip
Mailing Address (if different from home)

Mailing Address

Street Address Line 2

CityState

Zip
Marital Status*

SingleDomestic PartnerMarriedDivorcedSeparatedWidowed
Household Size (Ex: Jane Doe, March 1, 2002, Daughter) (Empty spaces write N/A)*
Household Income (You) *
Household Income (Spouse) Enter N/A if Not Applicable*
Household Income (Children) Enter N/A if Not Applicable*
Household Income (Other) Enter N/A if Not Applicable*
Household Income Total Amount (Add all entries and put total here)*
Other Income ( Type 0 if doesn't apply)*
Other Income Total Amount (Add all entries and put total here)*
Outside Expenses that affect your Annual household income. (please list expense & amount) *
Please list other expenses that may fall outside normal expenses for a household that affect your annual income. Please upload proof of extra annual expense. (This does not guarantee that this amount will be taken into consideration)
What services are you getting at OHL*
Please list all if more than one
NOTE: To comply with federal regulations, in order to give you a discount on our services, it is necessary for us to ask some personal questions. Your answers will be kept on file and in strict confidence. You must verify your income at least every year. Please upload yearly income tax return, copy of your W-2 form, last month's paycheck stubs, copies of your social security checks, or other checks you may receive as proof of family income. Only the family size and annual income will be used to determine your eligibility and calculate your discount.
Sliding Fee Scale

A - 80% DiscountB - 60% DiscountC - 40% DiscountD - 20% DiscountE - 0% Discount
File Upload *

Upload any files requested for proof of eligibility and income (i.e. yearly income tax return, copy of your W-2 form, last month's paycheck stubs, copies of your social security checks, or other checks you may receive as proof of family income.)
Cancelof
I do hereby swear or affirm that the information provided on this application is true and correct to the best of my knowledge and belief. I agree that any misleading or falsified information, and/or omissions may disqualify me from further consideration for the sliding fee program and will subject me to penalties under Federal Laws which may include fines and imprisonment. I further agree to inform Open Heart Leaders if there is a significant change in my income. If acceptance to the sliding fee program is obtained under this application, I will comply with all rules and regulations of Open Heart Leaders. I hereby acknowledge that I read the foregoing disclosure and understand it.
Name (Print)*
Date*

MonthDayYear
Date
Signature*

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Should be Empty:

Open Heart Leaders Sliding Scale Form