SLIDING FEE SCALE AND INCOME bVERIFICATION FORMb - unitycarenw 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your full name, email address, mailing address, and phone number. Indicate whether you would like detailed messages left at this number.
3. Select the appropriate checkbox to indicate the purpose of completing this form—either for household information for grants or to apply for a sliding fee scale discount.
4. In the household information section, list all members of your household along with their relationship to you, date of birth, health insurance status, employment status, gross monthly income, source of income, and tax dependency status.
5. On the back side of the form, check off which documents you will provide as proof of income. Ensure that you have one document for each source listed.
6. Finally, review your information for accuracy and sign the form. Initial where required to give permission for Unity Care NW’s Enrollment Specialists to access your income information.

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