Proof of Income Documents

Proof of Income Form
Patient Name

First NameLast Name
Please select a Community Based Clinic OR a School Based Clinic
Community Based Clinic

DermottEudoraMonticelloMonticello Women's HealthPortlandRisonSheridanStar CityStar City DentalUAMWarrenWilmot
School Based Clinic

Dermott School DistrictDrew Central School DistrictEudora School DistrictHamburg School DistrictLakeside School DistrictPulaski County Special School DistrictSheridan School DistrictStar City School DistrictWarren School District

Eligible documents include:

Tax Return

Letter from employer stating earnings

Letter from pastor stating no income

Bank Statements showing deposits (unemployments, Social Security, Food Stamps, or other public assistance)

W-2's
Documents Upload

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