Sliding Fee Application
Please complete this application to determine qualification for a reduced fee. You will be contacted within 48 hours to discuss fee and possible payment arrangements. Sliding fee application is based on the 2016 Federal Poverty Guidelines.
Please enter your initials
What is the total income of all member of your household (over age 18)? Please write in the amount of pre-tax income per month.
How many adults (18+) live in your home?
Do you have proof of income for all members of your home?
What is your preferred method of contact to discuss your application?
Please tell me your preferred email or phone number
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This form was created inside of Carolina Converge, PLLC.
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