2. Voucher Plan Application
4. First Name*
5. Last Name*
7. Phone Number*
8. Email Address*
10. Home Address*
11. City*
12. State*
13. Zip Code*
15. Date of Birth*
16. Driver License Number*
17. Driver License State*
19. Is your household income at or below the limits listed below?*

    1. Yes
    2. No
21. Household Size / Annual Income to Qualify for the Low Income Option
    • 1- $25,520
    • 2 - $34,480
    • 3 - $43,440
    • 4 - $52,400
    • 5 - $61,360
    • 6 - $70,320
23. Proof of Income

    Upload one of the following proofs of income here.

    • SNAP or EBT card
    • Women, Infants & Children (WIC) Supplemental Nutrition Program (screenshot of your phone app)
25. *Uploaded file must be less than 20 MB. File types are restricted to Microsoft Office file type, jpg, png, and pdf.
27. Requirements

    By submitting this form you (1) attest the information provided is true and accurate and (2) understand that Park Durham may conduct audits, and (3) if requested, you will be required to provide documentation proving your income level.
    
    Failure to respond will result in termination from the program and/or administrative fines.

29. I Agree to the requirements Above*

    1. Yes
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31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field