Financial Eligibility Form

Financial Assistance / Sliding-Scale Eligibility

HOUSEHOLD & INCOME INFORMATION

Please list household members .

Household Member 1

Household Member 2

Household Member 3

Household Member 4

2. Household Income

Please write the gross income amount before taxes and deductions in the blank spaces.

Proof of income documentation upon request.

Client Certification

I certify that the information provided on this form is true and accurate to the best of my knowledge. I understand that additional documentation may be requested to determine eligibility for financial assistance. I understand that providing false or incomplete information may result in the denial or reevaluation of financial assistance.