Application for Fee Assistance (Samaritan Fund)

Name

Email Address

Phone #

Address

Household Income

Family Size

Frequency Frequency Monthly Annually

Any additional considerations

Client Attestation Client Attestation I certify the above information is correct I can provide proof of income (pay-stubs or tax return)

I understand that I am responsible for paying any balance I accrue. I understand this reduced fee is a scholarship based on current financial information given to the center at the time of intake. If at any time my financial situation changes, I will inform the Center and supply updated information to be used in the determination of a new fee arrangement. I further understand that if I have accrued a credit balance at the time of service termination, those additional monies on my account will be applied to reimburse the Center for any scholarship funds that I have received. I understand that I am responsible for paying any balance I accrue. I understand this reduced fee is a scholarship based on current financial information given to the center at the time of intake. If at any time my financial situation changes, I will inform the Center and supply updated information to be used in the determination of a new fee arrangement. I further understand that if I have accrued a credit balance at the time of service termination, those additional monies on my account will be applied to reimburse the Center for any scholarship funds that I have received. I Agree