Application for Sliding Fee Scale Discount

  • If declined, you will not receive discounted services - if qualified
  • Please select one
  • WagesSalarySelf-employment IncomeLess expensesNet income for self-employment businessChild supportGovernment Check (list type)Other income (describe) 
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  • Those that live with you
    NameRelationshipBirth DateSocial Security Number 
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  • Signature