Total household yearly income and total number of dependents in household must be included with this intake form. "Number of people in household" includes client and the following individuals who live with client: client's spouse; client's biological, adoptive, or step-children under 18; client's biological or adoptive siblings under age 18. Supporting documents with regard to financial status must be submitted with this application, such as prior year's income tax return; prior year's W-2 forms; paycheck stubs; or statement from employer documenting earned wages for the period requested; or other proof of income as approved by Cancer Services of Grant County, Inc. A signed statement will be required from the client, guarantor, or representative attesting to the prior and/or financial status whereby documentation listed above what is not available.

I affirm all the information provided herein is true and correct to the best of my knowledge. I give Cancer Services of Grant County permission to discloseand receive information related to my case with associated providers as deemed necessary by Cancer Services of Grant County.