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Sliding Fee Schedule
Combined
Gross
Monthly
Income* Number of dependents (including yourselves)
2 3 4 5+
0-3000 $50.00 $50.00 $50.00 $50.00
3001-3500 $55.00 $50.00 $50.00 $50.00
3501-4000 $60.00 $55.00 $50.00 $50.00
4001-4500 $65.00 $60.00 $55.00 $50.00
4501-5000 $70.00 $65.00 $60.00 $55.00
5001-5500 $75.00 $70.00 $65.00 $60.00
5501-6000 $80.00 $75.00 $70.00 $65.00
6001-6500 $85.00 $80.00 $75.00 $70.00
6501-7000 $90.00 $85.00 $80.00 $75.00
7001-7500 $90.00 $90.00 $85.00 $80.00
7501-8000 $90.00 $90.00 $90.00 $85.00
8001-UP $90.00 $90.00 $90.00 $90.00
Name Gross Monthly Income
______________________________________________ ______________________
______________________________________________ ______________________
______________________________________________ ______________________
______________________________________________ ______________________
______________________________________________ ______________________
Combined Gross Monthly Income ________________________________________
Total Number of Dependents ________________________________________
Scheduled Hourly Fee ________________________________________
I hereby certify that all information provided above to determine my hourly fee is true to the best of my knowledge. I understand that if my financial status changes it is my responsibility to immediately notify this service provider to have my fee reevaluated.
____________________________________ ____________________________________
Client Date Client Date
*For the purposes of these computations, gross monthly income refers to total
household income before taxes and other deductions, and includes new spouses'
incomes and earned interest.
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