Sliding Scale Application Form

Sliding Scale Application Form
Personal Information

Please fill out this section completely.
Full Name of person completing this form*

First NameLast Name
Full Name of person you are completing this form for (If it is a minor, please put their name. If it is yourself, please re-enter your name)*

First NameLast Name
If you are filling this form out for a minor, are you considered a legal guardian?*

YesNoDoes not apply to me
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Have you applied for sliding scale from us before?*

YesNo
General Financial Information

Fill out the corresponding sections that best describes your situation.
What is your net monthly income?*
Do you receive income from any other source(s), (child support, alimony, etc.)?*

YesNo
What is the total of support/other income you receive per month? If this does not apply to you, please put $0.*
What is your total household income?*
How many minors are you supporting with your income? If this form is for a minor, how many siblings does the minor have that are being supported by the income?*
How much do you receive in Social Security benefits? If this does not apply to you, please put $0.*
How much do you receive in Unemployment benefits? If this does not apply to you, please put $0.*
Other Circumstances

In the space below, please describe any other reasons or circumstances (past, present, or future) that you feel increase your qualification and/or need for financial assistance. (e.g., family circumstances, sudden homelessness etc.).
Reason or Circumstance:
Conditions Upon Acceptance
As part of the application process, you are required to provide documentation of your current financial situation, such as recent pay stubs, income statements, or other relevant materials.

If your application is approved, the terms will remain in effect for 90 days, unless we are informed of a change in your financial circumstances. Should your need extend beyond the initial 90-day period, a re-evaluation will be necessary.

Please note, approval is granted in good faith, with the expectation that you will provide accurate and honest information regarding your income. We ask for your transparency, as the number of available approvals is limited and others are also in need of services.

Please also note that we reserve the right to revoke any approved sliding scale fee at any time if it is determined that false or misleading information was intentionally provided. In such cases, services may be discontinued and you may be referred to alternative providers.
Please upload appropriate documentation of your financial situation. If you are submitting paystubs, please submit your three most recent stubs. *

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Signatures
I affirm that the information in this form is true and accurate according to my knowledge.
Signature*

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Date*

DayMonthYear
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Sliding Scale Application Form

Personal Information

General Financial Information

Other Circumstances

Conditions Upon Acceptance

Signatures