*Do you have any other sources (family, clergy, church) that may be willing to YES NO
assist in the tuition payment.
If yes, how much do you feel they could contribute yr/monthly? ___________
* Have you ever filed for bankruptcy? If yes, please list the year(s) YES NO
*How much do you feel you are able to pay each month? $_________________
1Valley Behavioral Health FORM B
Carmen B. Pingree Autism Center of Learning
Application for Placement and Agreement to Pay with NO Financial Assistance (other than CSS) for 7th grade and above or Adjusted Gross Income over $115,000.00 and above.
2015-2016 Program Year
Please initial that all the following information is included prior to submitting application:
1. _____ That this form is completed in its entirety
2. _____ To attach a copy of your most recently filed federal tax return
3. _____ To attach copies of payroll check stubs for the previous three months
* Has your child previously been approved by the Utah State Office of Education to
receive Carson Smith Special Needs Scholarship Funds? YES NO
If NO, are you planning on applying for the Carson Smith Special Needs
Scholarship Funds YES NO
Have you every filed for bankruptcy? ______yes ______no Year: 19_____ 20____
I/We agree to pay a full tuition for the 2015-2016 program year, if my/our child is accepted into the VBH Carmen B Pingree Autism Center of Learning. I/We additionally agree to provide the listed information above at the time of application. Furthermore, I/We authorize any required verification, including a credit bureau report. I/We understand that if this information is determined to be false or deceptive, such a determination will result in denial of services and I/we will be liable for payment of charges for services rendered. I/We understand that some services provided may qualify for health insurance reimbursement and will be billed to my/our insurance plan. I/We further understand that the reimbursement received will be deducted from my obligation. Parent/Guardian Signature: _____________________________ Date: _______________
Parent/Guardian Signature:______________________________ Date: _______________
Are there any extenuating circumstances that should be taken into account in determining potential financial assistance? You may attach an additional letter if you would like.
I hereby state that the information given herein is true and complete. I authorize any required verification, including a credit bureau report. I understand that if this information is determined to be false or deceptive, such a determination will result in denial of uncompensated services and I will be liable of payment of charges for all services rendered.