The following list includes eligible sources for proof of income. All household members must provide proof of income in order to qualify for a sliding scale.

Proof of Income

• Most recent pay stub showing gross pay

• Signed Income verification letter form from employer stating wages

• Most recent signed 1040 tax return and/or all W-2’s for the prior year

• Public Assistance award letter (food stamps, temporary assistance, Public

Housing)

• Medicaid eligibility letter with income

• Head Start award letter

• Income statement from dividends, interest, and/or rent

• Social Security Income (SSI) statement

• Disability Income (SSDI) statement

• Retirement income statement

• Unemployment compensation statement

• Pension statement

• Workman’s Compensation

• Veterans Benefit

• Work Projection letter from Idaho Department of Labor

• Letter from sponsor or other affiliated organization stating income (SEICCA, WIC, Homeless Shelter, etc)

• Annual Self-Declaration of Income Form: Signed Self-declaration form is used as a last resort to state income or unemployment (requires a Patient Resource Coordinator of Clinic Administrator approval)