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In order to be considered for assistance, you must confirm that your household income is at or below the eligibility guidelines. By signing this form, you certify that you qualify according to the chart above.

Name *
Enter the number of people living in your household.
Enter your household annual income range.
Address *
Electronic Signature *
Date *
I acknowledge that Warren Health & Fitness board of directors has the final decision on who is rewarded assistance. *