AxessPointe Sliding-Fee Scale Application * = Required Name * Name First Name First Name Middle Initial Middle Initial Last Name Last Name Date of Birth * Social Security Number Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Home Phone * Cell Phone * Which number do you prefer? * Home Phone Cell Phone Spouse Name Spouse Name First Name First Name Middle Name Middle Name Last Name Last Name Date of Birth Social Security Number List of Dependent Claimed on Your Tax Return Name, Social Security Number, Date of Birth, Relationship You Must Bring Proof of Income * Most Recent Tax/Return/4506-T Notarized Letter of Support SS/Disability Award Letter Unemployment Award Letter Alimony/Child Support Decree Last 3-4 Paystubs from Each Member of House OtherOther Application Confirmation * I have completed this application for sliding-fee eligibility and confirm that all information is correct to the best of my knowledge. Decline Application Applicants Signature * signature keyboard Clear Date Signed * Submit If you are human, leave this field blank. AFS Contact Us Name * Last * Email * Subject * Message * Captcha Submit If you are human, leave this field blank.
