Sliding Fee Scale/Financial Hardship Form
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Personal Information:

Full Name, Address, Phone Number, Email Address, Date of Birth:

Household Information:

Number of people in your household (including yourself):
Number of dependents:
Relationship to dependents (e.g., spouse, children, parents):

Employment Information:

Are you currently employed? (Yes/No)

Employer’s Name:

Employer’s Address:

Employment Status (Full-time, Part-time, 

Unemployed, Self-employed):

Job Title/Occupation:

Length of Employment:

If unemployed, how long have you been unemployed?

Monthly Expenses:

Rent/Mortgage Payment:

Utilities (electricity, water, gas):

Transportation Costs (car payments, fuel, public transportation):

Food/Groceries:

Health Insurance Premiums:

Medical Expenses (co-pays, medications):Childcare Costs:

Other Monthly Expenses (e.g., credit card payments, student loans, insurance):

Requested Discount:

Are you requesting a specific discount or fee adjustment? If so, what percentage or amount are you requesting?

Income Information:

Total Gross Monthly Income (before taxes):

Total Net Monthly Income (after taxes):

Sources of Income (e.g., wages, social security, unemployment benefits, child support):

Do you receive any additional financial support? (Yes/No) If yes, please explain:

Please briefly explain why you are in need of an alternative fee schedule. *
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