Sliding Scale Application |

Your Full Name *

First

Last

Client's Full Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Email *

New or Existing Client *

Service Requested *

Please list all household members, including those under age 18. Please include the relationship to the applicant and each member's date of birth. *

Household's annual wages, salaries, tips, etc.

Household's annual income from business and self-employment

Household's annual unemployment compensation, workers’ compensation, Social Security, Supplemental Security Income, public assistance, veterans’ payments, survivor benefits, pension or retirement income

Household's interest; dividends; royalties; income from rental properties, estates, and trusts; alimony; child support; assistance from outside the household; and other miscellaneous sources

Income Verification *

Click or drag files to this area to upload. You can upload up to 5 files.

Applicants may provide one of the following: prior year W-2, two most recent pay stubs, letter from employer, or Form 4506-T (if W-2 not filed).

Signature *

I certify that the family size and income information shown above is correct.