Sliding Scale Application

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This information is collected for consideration of the NAMI DuPage Peer Counseling Sliding Fee Scale rate. The Sliding Fee Scale rates are determined by the annual Federal Poverty Level Guidelines published by the US Department of Health and Human Services.

Re-certification of Sliding Fee Scale rate eligibility is required, annually, based on the the date of eligibility.

Please include all cash income from the past 90-days. Include the MONTHLY GROSS dollar amount in the space provided. Copies of support documentation will be required for eligibility verification.

See below for acceptable sources of income documentation.

Client Name *

Do you or a household* member 18 years old or older receive OR expect to receive income from: Employment wages or salaries? (Include overtime, tips, bonuses, commissions, and payments received in cash) *

Yes

Number of people in your household? *

*Household Definition, as defined by the Affordable Care Act: "A 'household' consists of a person filing an income tax return and those for whom he or she claims a personal exemption. These are generally those listed as dependents. If the person filing the return lives with others but is not claimed as a dependent by any of them, he or she would comprise a separate household. Unless that person has dependents, only his or her earnings would be considered in determining the household's income." *

Check that you understand the definition of "Household"

Are you currently Employed? *

Yes

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