Financial Assistance Application Form Page 2
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2Financial Assistance Application Form
SECTION FOUR: FAMILY INFORMATION Please provide income for yourself and all other household members listed on your tax return
Name
Social Security
Relationship
Date of Birth
Applicant?
Employed?
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
SECTION FIVE: ASSETS Please list all assets and their current value
Circle
Total Current
Do You Have?
Description
Type of Verification Required
Choice
Value
Checking Accounts (total balances)
Yes / No
Most current bank statement(s)
Savings Accounts (total balances)
Yes / No
Most current bank statement(s)
CD’s/Stocks/Bonds
Most current investor statement(s)
Yes / No
Second Home (not your primary
Yes / No
Tax assessment
residence)
Land
Yes / No
Tax assessment
Vehicles (Cars or Trucks)
Tax assessment
1.
Yes / No
2.
Yes / No
3.
Yes / No
Camper/RV
Yes / No
Tax assessment
Other Recreational Vehicles
Yes / No
Tax assessment
(Boats/Motorcycles/ATVs)
Other
Yes / No
Tax assessment
Please provide any additional information about assets listed above that you would like to have included in your application:
________________________________________________________________________________________________________________________
By my signing below, I certify that everything I have stated on this application and on any attachments is true.
Responsible Party Signature: X_______________________________________________________ Date: ____________________________
Return To:
Office Use Only
West Virginia University Hospitals
Approved
Due Date______________________________
Patient Financial Services
PO Box 8031
Denied
Tracking Number________________________
Morgantown, WV 26506
304-285-7202
Page 2
Policy II.015 Exhibit I Eff 01/01/2015
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Parent category: Business