Financial Form

To be considered for the sliding scale fee, the participant must have a diagnosis of dementia and this form must be completed. If you choose not to complete this form, the rate will be $15.00 per hour.

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Gross Monthly Income (Social Security, VA benefits, Pensions, Alimony, Estate or Trust Funds, Interest Income, Employment, SSI, Other)

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Assets (Savings, Checking, Equity/Real Estate, Stock, CD, IRA, Money Market, Cash Value Life Insurance)

[contact-field label=’Participant’ type=’text’/][contact-field label=’Spouse’ type=’text’/][contact-field label=’Total Household Expenses’ type=’text’/]

Current Monthly Medical Expenses (Prescriptions, Medicare Premiums, Insurance Premiums, Over the Counter Medications, Doctor Visits, Bills

[contact-field label=’Participant’ type=’text’/][contact-field label=’Spouse’ type=’text’/][contact-field label=’Total Medical Expenses (Participant + Spouse)’ type=’text’/]

Adjusted Monthly Income

[contact-field label=’Total Monthly Income’ type=’text’/][contact-field label='(minus) Total Household Expenses’ type=’text’/][contact-field label='(minus) Total Medical Expenses’ type=’text’/][contact-field label='(equals) Adjusted Net Monthly Income’ type=’text’/][contact-field label=’Electronic Signature’ type=’name’ required=’1’/][contact-field label=’Date’ type=’text’ required=’1’/][/contact-form]