Language
English (US)
Self Information
Please provide the requested information about the individual that is applying for the Sliding Discount Program.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Weekly Income
*
Monthly Income
Annual Income
Make sure to include all sources of income in the weekly salary calculation.
Weekly Salary Calculation Tool
Spouse and/or Partners Information
Please provide the requested information of your spouse and/or partner that lives at the same household.
Spouse / Partners Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Weekly Income
Monthly Income
Annual Income
Spouse Counter
Household Dependents
Relatives over 18 (that are not full-time students) are not eligible to be used as dependents for this application process.
Number of Household Dependents
*
Please Select
0
1
2
3
4
5
(1) Dependent Name
First Name
Last Name
(1) Date of Birth
-
Month
-
Day
Year
Date
(1) Weekly Income
(1) Monthly Income
(1) Annual Income
(2) Dependent Name
First Name
Last Name
(2) Date of Birth
-
Month
-
Day
Year
Date
(2) Weekly Income
(2) Monthly Income
(2) Annual Income
(3) Dependent Name
First Name
Last Name
(3) Date of Birth
-
Month
-
Day
Year
Date
(3) Weekly Income
(3) Monthly Income
(3) Annual Income
(4) Dependent Name
First Name
Last Name
(4) Date of Birth
-
Month
-
Day
Year
Date
(4) Weekly Income
(4) Monthly Income
(4) Annual Income
(5) Dependent Name
First Name
Last Name
(5) Date of Birth
-
Month
-
Day
Year
Date
(5) Weekly Income
(5) Monthly Income
(5) Annual Income
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Household Totals
Your total number of household members and combined income will automatically be calculated in the fields below.
Total Household Members
Total Annual Income
You will also need to provide one of the following proof of income, for those individuals listed within the application: Pay Stubs showing last four weeks of income Completed Employment Verification Form Unemployment Compensation showing last four weeks of income Workers Compensation showing last four weeks of income Social Security Income (SSI) Disability or SSI Benefits Letter Documentation from a Local, State or Federal Agency Letter of Support from Charitable Organization Last year’s Income Tax Return including W-2 or 1099 (only if Self-Employed)
Proof of Income
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Attach proof of income for those individuals listed within the application.
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Patient Agreement
*
I certify that the above facts are true and correct to the best of my knowledge. I am also aware that this information may be randomly audited at any time for verification purposes. Knowingly providing false information may result in termination of services.
Signature
*
Clear
Date
-
Month
-
Day
Year
Date
Submit
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