Indigency Waiver Request Form
Complete this form to request a waiver based on inability to pay. All information is required for evaluation.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Waiver Requested
*
Household Size
*
Monthly Household Income (approximate, no account numbers required)
*
Briefly explain your financial hardship or reason for requesting this waiver
*
Upload supporting documentation (optional)
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