Sliding Scale Discount Attestation

Sliding Scale Discount Attestation Applicant Form

This form is only to be completed if proof of income is not provided or additional information needs to be provided. Please complete all sections that apply.
What would you like to do to complete your Sliding Scale Discount application?*

Complete the attestation formUpload supporting documentation
Applicant's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Upload Supporting Documentation*

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Instructions for Attestation
1. Download and print the Sliding Scale Discount Attestation Form (PDF).
2. Fill out the form completely and sign it.
3. Once finished, scan or take a clear photo of the completed form.
4. Upload the completed PDF (or image file) as supporting documentation in this application.
Click the ellipsis (…) on the far right to save or print the document.
Click the ellipsis (…) on the far right to save or print the document.
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Sliding Scale Discount Attestation Applicant Form