Sliding Scale Application Form

Sliding Scale Application Form

Jason Surrogate Partner serves all clients regardless of inability to pay. Lower fees are offered to a limited number of clients. Discount based on client income level compared to Federal Poverty Guidelines.
Name

First NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Postal Address
If different than home address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth

MonthDayYear
Social Security Number *
Nationality
Marital Status
Marginalized Group Identity

Check all that apply.
Explain marginalized group

Household Size

Household Income

Other Income

Federal Income Tax Form

Cancelof
W-2 form(s)

Cancelof
3 Pay Statements

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. I further agree to inform Jason Surrogate Partner 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 payment obligations of Jason Surrogate Parner. I hereby acknowledge that I read the foregoing disclosure and understand it.
Date

MonthDayYear
Date
Signature
Should be Empty:

Marginalized Group Identity