Personal Documentation

Below you will find 3 forms of personal documentation that are required to apply for both discounted dental services with Grassroots Dental, and also to apply for financial assistance with dental services.  Please make sure to pay close attention to what documents are acceptable, because each category is specific.

If you fail to provide, or if you provide any other kind of document than what is listed, the process of reviewing your application may be delayed. If this is the case, you will be contacted by email from a member of our Support Team who will ask you for the correct documents.

(scroll down to next section for Income Documentation)

State-Issued, Not Expired

If your Photo ID does not verify your current home address, please also upload a picture of a utility bill OR official letter showing your home address for verification.

Valid
Photo
ID


Card issued by the Social Security Administration

Not Accepted: Medicare/Medicaid Card, Tax Returns, or any official letter.

Social
Security
Card


Proof
of
Citizenship

Please choose ONE from the following 3 options:

  1. Birth Certificate - with visible authorized signature and official seal
  2. Valid Passport
  3. Green Card

No other documents are accepted apart from the 3 options listed above.


 

Income Documentation

Below you will find a list of acceptable documents to verify your source(s) of household income. Please make sure to pay close attention to what documents are accepted, because each category is specific.

If you provide any other kind of document than what is listed, the process of reviewing your application may be delayed. If this is the case, you will be contacted by email from a member of our Support Team who will ask you for the correct documents.

 

Wages

2 months of current and consecutive pay stubs.

Example: If your pay frequency is bi-weekly (every other week, or twice per month,) you will need to upload the most recent 2 months worth of check stubs with dates that are consecutive.


SSI

Supplemental Security
Income

2017 Explanation of Monthly Benefits Letter


Pension

Official letter explaining monthly benefits


Housing Assistance

Official letter explaining monthly benefits


Official letter explaining monthly benefits

Retirement


2017 Explanation of Monthly Benefits Letter

Social Security


Official letter explaining monthly benefits

Veteran's Benefits


2017 Explanation of Monthly Benefits Letter

Disability


2017 Explanation of Monthly Benefits Letter

TANF


2017 Explanation of Monthly Benefits Letter

Unemployment


Official letter explaining monthly benefits

Child Support


Official letter explaining monthly benefits

Alimony


Official letter explaining monthly benefits

Worker's Compensation


Official document of Rental Agreement

Rental Income


Bank Statement displaying monthly deposits

Investments


2017 Explanation of Monthly Benefits Letter

Food Stamps/WIC


2 months of current and consecutive pay stubs

Self-Certification of Self-Employment


Please write a short letter explaining that you currently have no form of income.

Include: the dateyour name printed and your signature. This letter can be hand-written OR typed, however your signature needs to be hand-written.

Self-Certification of No Income