Squeaky Clean Queens - Income Verification Form
Please complete this form in full to help us determine your eligibility for our sliding scale program. Incomplete submissions may delay the processing of your application, affect service delivery, or result in denial. All information provided is kept strictly confidential and is used solely to determine eligibility.
Applicants Contact Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
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Eligibility Verification
Please select all types of government assistance you are currently receiving from the options below.
Snap/EBT
MFIP
Medical Assistance
Housing Assistance
SSI or SSDI
Please upload proof of at least one form of government assistance you currently receive. All documents must be current and include your first and last name as listed on this application.
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Additional Information (Optional): Please describe any financial hardships you would like us to consider when reviewing your application
Service Requested
Please select the service you are inquiring about from the list below.
General Cleaning
Deep Cleaning
Move - In / Move - Out Cleaning
Decluttering & Organization
Sliding Fee Payment Proposal
We understand that times can be tough -- that is why we offer a sliding fee scale for clients who are receiving government assistance
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