OHL Sliding Scale Form

Open Heart Leaders Sliding Scale Form

2026 Sliding Fee ScaleEffective January 1, 2026 – December 31, 2026 PurposeOpen Heart Leaders (OHL) is committed to ensuring that financial hardship does not prevent eligible individuals and families from accessing services. OHL’s Sliding Fee Scale provides reduced fees based on household size and household income. Eligibility for a reduced fee is determined using the 2026 Federal Poverty Guidelines (FPL).
First Name
Middle
Last
Other names
Who are you currently receiving services from?
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Home Address

Home Address

Street Address Line 2

CityState

Zip
Marital Status
Household Size including You
Household Income (You)
Household Income (Other) Enter N/A if Not Applicable
Household Income Total Amount Monthly
Household Income Total Amount Annually
Outside Expenses that affect your Annual household income. (please list expense & amount)
Financial Hardship Exception OHL recognizes that household income alone may not fully reflect a client’s ability to pay. When appropriate and permitted by the applicable funding source, OHL may approve an additional financial-hardship reduction based on documented circumstances such as unemployment, housing instability, significant dependent-care obligations, or other substantial financial hardship. Approval of an exception should be documented in the client’s record.
What services are you getting at OHL
Please list all if more than one
Eligibility and Documentation

Applicants requesting sliding-fee assistance should provide documentation sufficient to establish household size and household income.

Acceptable income documentation may include, as applicable:

·      Recent pay stubs

·      W-2 or 1099

·      Most recent federal tax return

·      Social Security or disability benefit statement

·      Unemployment benefit statement

·      Pension or retirement income documentation

·      Other documentation reasonably establishing household income

When standard documentation is unavailable, OHL may permit an applicant to complete a self-declaration of income, subject to OHL policy and any requirements of the funding source supporting the service.
Eligibility Documentation 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.
Annual Review

This Sliding Fee Scale is reviewed and updated annually following publication of the new Federal Poverty Guidelines.

Clients receiving sliding-fee assistance may also be required to have their eligibility reviewed periodically or when there is a significant change in household income or household size.
Name (Print)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

Open Heart Leaders Sliding Scale Form