Charity Forms - Rocky Mountain Infectious Disease Specialists

This information is STRICTLY CONFIDENTIAL. Please complete this form listing everyone in your household and their annual income.

Applicant Name*

First Last

Date of Birth*

Address*

Address City State Zip

Phone*

Email*

How would you prefer we contact you?*

If you do not have income from the past month, and are going to self-attest, please mark the box, fill out the household assessment below, and the statement attached.*

I am self-attesting (continue to Self-Attestation Statement
I am applying for the sliding fee and proving income verification (complete the below form, listing everyone in your household who would be included on your tax return)

Full Name	Relation to #1	Date of Birth	Birth Sex	Social Security Number	Total MONTHLY Income	Total ANNUAL Income	Source (Job, SSDI, etc)

Step 1 of 3 - Sliding Fee Application

SLIDING FEE APPLICATION

SELF-ATTESTATION WITH NO INCOME