List your monthly expenses below (bills or fees paid to whom and in what amount):
The completion of this application is not a guarantee for funding. Applications are approved on a case-by-case basis and subject to program availability. I understand that I am applying for subsidized services through a donor-funded program available at JSHC for either myself or a person under my care. I understand that intentionally falsifying information is grounds for termination of services and dismissal from the practice. By signing below I confirm that the information provided is true and accurate.