Financial Hardship Application

Proof of Income

To be eligible for a financial hardship waiver, your income must not exceed 200% of the Federal Poverty Guidelines. A sample of the current income thresholds is provided below. Please refer to the full federal guideline form for additional details.

Acceptable proof of income may include:

• W-2 withholding statements
• Unemployment check stubs
• Paycheck stubs
• Tax return (1040)
• Medicaid or other state-funded medical assistance documents
• Employer forms or letters
• Documentation from welfare or community aid programs

Additional documentation may include proof of financial hardship, such as:

• Bankruptcy settlement
• Death or disability in the family
• Catastrophic circumstances or other compelling reasons showing inability to pay