Reduced Cost Application

We are committed to making our services accessible to all families. Please complete this application to determine your eligibility for sliding-scale pricing. Eligibility shall be reviewed every six months to ensure continued qualification. Parties may be required to provide updated documentation during each review period. If you have any questions or concerns regarding this form or required documentation, please reach out to our office at info@throughthevale.com or (916) 360 - 0364.

Applicant Information

First name

Last name

Date of Birth

Month

Day

Year

Phone

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Household Information

Total number of people in the household

Minor Children (Age 0 - 17)

Adults (Age 18 - 64)

Seniors (Age 65+)

Yearly Household Income

Primary Source

Would you like to add any additional household information?

Personal Circumstances

Why are you requesting reduced pricing?

Please attached one or more supporting documents below:

Recent pay stubs (last two months)
Most recent tax return
Proof of government assistance (e.g., SNAP, TANF, WIC)
Any additional documents supporting your request

Type of document attached

Pay Stub

Tax Return

Government Assistance

Other

Income Documentation

Acknowledgment

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that falsification of information may result in denial of services or invoice adjustment.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.