RISE - Sliding Scale Agreement Application
Standard online application for sliding scale fee determination. Match the original PDF structure and field labels as closely as possible; all fields are optional unless clearly required.
Applicant Information
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Applicant Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Gender
Male
Female
Non-binary
Household Information
Number of People Living in the Household
Household Members
Employment & Income Information
Employment Status
Full-time
Part-time
Self-Employed
Unemployed
Student
Retired
Disabled
Employer Name
Annual Household Income (before taxes)
Additional Sources of Income
Additional sources of income
Child Support
SSI/SSDI
Unemployment
SNAP Benefits
Other
If 'Other', please specify
Agreement & Signature
Certification Statement
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Office Use Only
Approved Sliding Scale Fee ($)
Effective Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reviewed By
Submit
Submit
Status
Approved
Denied
Additional Information Requested
Should be Empty: