JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Reduced Fee Application - New Clients
REDUCED FEE APPLICATION. Please note that this form is secure. The information gathered here will be used for the sole purpose of determination of qualification for a reduced fee.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Name
Your answer
Email & Phone Number:
Your answer
Gross (Before Taxes)
Household Income
This
Month:
Your answer
Do you or a minor child have WIC? *You may be asked to present your WIC Card*
Yes
No
Not Sure
Clear selection
Household Size (If you are currently pregnant or have experienced a perinatal loss in the last year, add 1)
*
Your answer
Household Income (Per Last Year's Taxes). You may be asked for proof of income.
*
Your answer
Are you currently on medical or parental leave? If so, what are your leave benefits (past or current)? (Paid? At What Percentage? For How Long?)
*
Your answer
I attest that the information provided here is true and correct. I will be able to provide supporting documentation if requested.
*
Yes
I understand that if I qualify for a reduced fee; my eligibility will be reassessed quarterly.
*
Yes
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Mary Frances LaHood.
Does this form look suspicious?
Report
Forms
