I declare under penalty and perjury that the answers I have given are true and correct to the best of my knowledge. I agree to tell Dedicated Sleep, TMD & Implants within 10 days if there are any changes in my income, property, or expenses. I understand we may be asked to prove my statement and that my eligibility statements will be subject to verification as deemed necessary by Dedicated Sleep, TMD & Implants. I understand that Dedicated Sleep, TMD & Implants is required to keep any information I provide confidential. I understand that if I do not qualify for a scholarship of services, I will be responsible for my out-of-pocket maximum in order to proceed with services rendered by Dedicated Sleep, TMD & Implants.