Fee Application Test

Please complete the following information for any other members of your household:

Please complete the following information for any other members of your household:

Please complete the following information for any other members of your household:

Please complete the following information for any other members of your household:

Please complete the following information for any other members of your household:

In order to qualify for the sliding fee, I am signing this letter which serves as a "Self Declaration" indicating that I have no income from any sources. I understand that I am responsible for my co-pay once I qualify for CHC's Sliding Fee. I fully understand the importance of reporting any income changes.

Please attach proof/verification for each of the income sources indicated above.

Type your name below to certify that the above information concerning my income is true and complete and that I have no income other than that listed above. I promise to notify CHC at once if there is a change in my income, family size, mailing address, or telephone number.