Sicilian
English (United States)
English (UK)
Albanian
Arabic
Aragonese
Armenian
Assamese
Aymara
Azerbaijani
Basque
Belarusian
Bengali
Bhojpuri
Bosnian
Breton
Bulgarian
Cantonese
Catalan
Cebuano
Chinese (China)
Chinese (Hong Kong)
Croatian
Czech
Dari
Dutch
Dzongkha
English (Australia)
English (New Zealand)
English (South Africa)
Esperanto
Estonian
Finnish
French (France)
French (Belgium)
French (Canada)
Frisian
Friulian
Galician
German
Gujarati
Haitian Creole
Hausa
Hazaragi
Hebrew
Hungarian
Icelandic
Igbo
Indonesian
Irish
Italian
Japanese
Javanese
Kabyle
Kapampangan
Kazakh
Khmer
Konkani
Korean
Kurdish
Kurdish
Kyrgyz
Lao
Latin
Latvian
Lingala
Lithuanian
Lombard
Macedonian
Malagasy
Maithili
Malay
Malayalam
Maori
Marathi
Maltese
Mongolian
Moroccan Arabic
Myanmar
Nepali
Norwegian
Norwegian
Occitan
Pangasinan
Panjabi
Pashto
Persian
Persian (Afghanistan)
Polish
Portuguese (Angola)
Portuguese (Brazil)
Portuguese (Portugal)
Quechua
Rohingya
Romanian
Russian
Sakha
Sanskrit
Saraiki
Scottish Gaelic
Serbian
Silesian
Sinhala
Slovak
Sindhi
Slovenian
South Azerbaijani
Spanish (Argentina)
Spanish (Chile)
Spanish (Colombia)
Spanish (Dominican Republic)
Spanish (Ecuador)
Spanish (Guatemala)
Spanish (Mexico)
Spanish (Peru)
Spanish (Puerto Rico)
Spanish (Spain)
Spanish (Uruguay)
Spanish (Venezuela)
Sundanese
Swahili
Swedish
Thai
Tagalog
Tahitian
Tajik
Tamil
Tamil (Sri Lanka)
Tatar
Telugu
Tibetan
Tswana
Turkish
Turkmen
Ukrainian
Urdu
Uzbek
Uighur
Vietnamese
Welsh
Wolof
Xhosa

STIPEND PAYMENTS – GLOBAL
| Patient |
| If the sponsor has approved stipend payments for this study. |
| Site coordinators, please have the patient fill out the Patient Payment Declaration Form below and upload it to our portal with the first stipend request. (1 time only for each new patient). |
| Download the Patient Payment Declaration Form here |
| OR use online form below if you need to translate into a different language. |
| Online Declaration Form |
| Payments will be made via a reloadable Visa card. |
| Colpitts Clinical will provide patients with an itemized report each January showing the prior year’s stipend payments, if needed for their tax preparation. |
