Stackbit - Application for Sliding Scale Fee

Contact Details
Name

First Name Last Name
Spouse and Family Information - please include name of spouse, occupation status and number of dependents
Do you have a church or other organization sponsorship? If yes, please include the name and contact information of the representative.
Income Information
Work Information

Full Time Work Part Time Work Full Time Student Part Time Student Not Employed
Please upload proof of income such as:
- recent paycheck stub
- first page of most recent tax return
Upload Files

Cancel of
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 Household Monthly Income:
Please include all members of the household.
Is there any additional information you'd like us to consider?
*Your signature below indicates that the information you have provided above is truthful.
Date

Month Day Year
Signature

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Contact Details