PDF Sierra Vista Community Health Center - Sliding Fee Scale Application 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Name of Head of Household' at the top of the form. Ensure accuracy as this information is crucial for processing your application.
3. Fill in your 'Address', 'State', 'City', and 'Zip' code. This helps establish your residency and eligibility for services.
4. Provide a contact 'Phone' number where you can be reached for any follow-up questions regarding your application.
5. List yourself, your spouse, and all dependents under age 18 in the designated section. Include their names and dates of birth to ensure proper family size assessment.
6. In the income section, detail all sources of income for yourself and your spouse. Be thorough in listing gross wages, self-employment income, unemployment compensation, and any other relevant financial support.
7. Review the certification statement at the bottom of the form. Sign and date it to confirm that all information provided is accurate.

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