Good Faith Financial Assessment


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Please complete the following information completely and to the best of your ability.

Shipping Address for Device

Caregiver Information

Requested Device(Required)
Requested Accessories

Financial Information

Please provide as much information as possible. The financial information provided is used to calculate a discount based on our sliding scale.

I hereby acknowledge that the information given herein is true and correct. I authorize Lingraphica to verify any information contained in this document for the sole purpose of assessing financial need.

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