reduced rate application

For clients who do not meet the requirements for the sliding fee scale but are still in need of financial support, NEW has a a limited number of reduced rate scale counseling slots. The reduced rate scale which is also based on federal poverty guidelines takes into consideration additional factors that may contribute to difficulty in paying the full rate that are not considered in the sliding fee scale. Clients who do not qualify for the sliding fee scale and want to be considered for the reduced rate scale must also complete the application, provide income and expense information and recertify every 6 months or if/and when your financial situation changes. All applicants will be required to complete the expenses and additional information section and provide income documentation (most recent pay stubs, most recent federal tax forms, P& L Statement for business and self employment income) once contacted by administrative team. Additional information about the Federal Poverty Guidelines can be found here.

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Household Members

Please add the name and date of birth for all household members.

First Name

Last Name

Date of Birth

YYYY

Name

First Name

Last Name

Date of Birth

YYYY

Name

First Name

Last Name

Date of Birth

YYYY

Additional Household Members

Please add any additional household members names and DOB in the space provided.

Total Number of Household Members

Income Sources

Check all that apply.

Gross wages, salaries, tips, etc.

Income from business and self-employment

Unemployment compensation, workers' compensation, Social Security, Supplemental Security Income, public assistance, veterans' payments, survivor benefits, pension or retirement income

Other

If other, please provide detail

Total Amount of Income

Please add total for each household members income.

Expenses

Please list all household expenses.

Additional Information

Please use this are to provide any additional information you would like considered in your sliding fee scale application.

I certify, that the family size, income and expenses information shown above is all correct and true to the best of my ability.