Proof of income is required. Please provide the following:
If self-employed, three month Profit and Loss statement and most recent tax return
Income Tax Forms, valid January Through April only
4 most recent pay stubs, including year-to-date totals from all employers.
Written explanation of current financial situation - Notarized.
Denial notice from the Department of Human Services or other proof of your income.
For patients completing this application to justify lower monthly payments, please include the following information related to expenses.
Monthly Expenses: List all monthly expenses that apply.