Application

Application/Verification of Financial Information

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Date / Time
Name
month/day/year
Address
Do you work Full Time or Part Time?
Employer Address
Provide 2 months pay stubs and most recent W2. Upload photos below.
Click or drag files to this area to upload. You can upload up to 4 files.
Click or drag files to this area to upload. You can upload up to 4 files.
Housing
Marital Status
Please list every person living with you below
Name of Person 2 Living in Home (other than you)
Name of Person 3 Living in Home
Name of Person 4 Living in Home
Name of Person 5 Living in Home
Name of Person 5 Living in Home
Name of Person 6 Living in Home
Do you or any members of your household receive any of the following benefits? If so, please provide a copy of the award statements for each, and list the monthly amount received .
Please list the monthly amount received from each below.
Click or drag files to this area to upload. You can upload up to 4 files.
Are other members of your household employed?
List annual income in above box. Upload files below.
Click or drag files to this area to upload. You can upload up to 2 files.
You can take a photo of the pay stubs with your phone and upload the pictures here. Upload W2.
What is your Total Household Income?
Do you have Dental insurance?
Do you have Health insurance?
Do you have Medicaid?

By submitting this application, I certify that the information contained in this form is true and correct to the best of my knowledge. I hereby grant permission for 5:16 Clinic and its agents to verify my employment, income, insurance coverage, Medicaid status and any other pertinent information needed to determine if I qualify for free dental and/or medical services.