COUNTY OF SANTA BARBARA

APPLICATION FOR FEE REDUCTION

CONFIDENTIAL

FINANCIAL DECLARATION


COMPLETE AND TURN IN WITHIN 2 WEEKS OF ENROLLMENT DATE

 

Full name (please print)

 

Date of Birth:

Social Security No:

Address:                                 Street                                                            City                                     State                   Zip

Cell Phone #

Work phone#

Marital Status:     o Single      o Married      o Separated     o Divorced      o Common-law 

# of Dependents:

Relationship and age:

Employer:

Spouse/Partner Employer:

Address:

Address:

Length of time at job:

Supervisor:

Length of time at job:

Supervisor:

Take home pay $

***Must provide 3 recent pay stubs

Week/Month

 

Take home pay $

***Must provide 3 recent pay stubs

Week/Mo

 

Unemployed benefits – Take home $                             Week/Mo

Unemployed benefits  – Take home $                            Week/Mo

 


Monthly Expenses (Self & Spouse)

Other Income/ Assets (Self & Spouse)

***MUST PROVIDE COPIES***

 

Rent:                        Mortgage:

$

Unemployment

$

Utilities:

$

Child support:

$

Food:

$

Disability:

$

Child support:

$

Social Security payments:

$

Child care items:

$

Food Stamps/CalFresh:

$

Cell phone bill:

$

SSI/SSP/General relief:

$

Car payment:

$

Rental income:

$

Car insurance:

$

Checking account current balance:

$

Health insurance:

$

Saving account current balance:

$

Laundry/clothes:

$

Cash on hand:

$

Entertainment/eat out:

$

WorkerÕs compensation

$

Other:

$

Retirement:

 

 

 

Other income provided by others:

 

Total

$

Total

$

 

I,                                                                                  (your name), declare under penalty of perjury under the laws of the State of California that the information provided on all pages of this form and any attached document provided is true and accurate.                                          Date:

 


        anger management specialists                                         www.amspecialists.org

Main Office                                                                                                       Locations                                                                                         
805.845.2900                                                                                                  16 West Mission Street, Suite T, Santa Barbara
Fax 805.456.0151                                                            433 North H Street, Suite F, Lompoc CA 94346         
Email: amsbip@gmail.com                                                                                           501 S. McClelland St., Santa Maria, CA 93454