LETTER OF SUPPORT FOR INDIVIDUALS WITH NO INCOME

LETTER OF SUPPORT FOR INDIVIDUALS WITH NO INCOME

If you receive support (e.g. Food, Housing, Financial Support) from a family member or friend please, have the
person who provides support complete this letter for you to receive the sliding fee discount.

Supporter: If the person you are filling this form out for lives with you, we will need copies of your monthly income
for them to receive the discount.

I, Supporters Name:

Provide

With the following services

(Check all that apply)

Supporter: The person I am providing support for

live with me. (Select one)

I believe the monthly, dollar value of these services to be approximately:

THANK YOU FOR CHOOSING ACCELHEALTH!