subject_line
Client Name
*
Are you on Social Security/disability?
*
Yes
No
Are you a juvenile?
*
Yes
No
Do you currently serve or were you honorably discharged from the military?
*
Yes
No
Do you have a public defender or court appointed attorney?
*
Yes
No
Are you unemployed?
*
Yes
No
* If you answered "YES" to any of the above questions you DO NOT need to answer the remaining questions.
Source of Income: (Include employer and phone#)
Position
Total Annual Household Income:
Number of Qualified Dependents: (People you claim on your taxes)
Are you enrolled in ADL's Autopay Program?
*
Yes
No
* If approved this discount (credit) will be in effect for 90 days, after which the daily credit will
be discontinued. Credit may be renewed upon re-verification of income.
Under penalty of law, I submit the information provided on this form is true and accurate.
*
clear
Date
*
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