Sliding Scale Worksheet printable pdf download

Sliding Scale Worksheet

SLIDING SCALE WORKSHEET

Use this worksheet to determine your Sliding Scale Fee per Service on our Sliding Scale

Fee Chart. You will be asked to resubmit your Net Annual Household Income once

annually. If you have an unpredictable or changing income, you may resubmit as often

as 1x month. All information contained herein will be kept confidential in accordance

with HIPAA guidelines.

Net Monthly Household Income

Income of all adult earners after taxes, benefits and voluntary deductions are made from wages.

Your Occupation/s _

_ ________________________________________________________________

Your Net Monthly Earned Income

$ _ ______________

= ‘A’

( Wage, Salaried, or Contracted*)

* If contracted, please deduct 25% for tax filing

Your Other Monthly Income:

Circle Y / N to indicate whether you receive the following income. If Y, enter amount received

Y / N

Unemployment Compensation

Public Assistance

Y / N

( SSI, SNAP, TANF, Disability or other monetary support)

Y / N

Student Loan Income:

Child Support and/or Alimony:

Y / N

Investment and/or Insurance Income

Y / N

Family Support

( trust disbursements, gifts, tuition coverage, rent subsidy)

Y / N

Rental Property (includes AirBnB):

Y / N

Pension and/or Veteran’s Pension

Y / N

Tips / Gratuities (if not included in Wage above)

Y / N

Funds received from other adult earner/s in household

Y / N

Other Income (i.e,. passive income streams)

Sum of Other Monthly Income = ‘B’ $ _ ________

Add together ‘A’ + ‘B’ to get Total Monthly Income = ‘C’ $ _ ________

Sliding Scale Worksheet