Albany Medical Center Page 2
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3Income Information for all Household Members
Please check all that apply and fill in the estimated net amount for the last 3 months:
Patient
Spouse
Other household members
Income (Salary)
Interest Income
Social Security Benefits
Disability
Unemployment
Worker’s Comp
Pension
Child Support
Education Stipends
Veteran Benefits
Public Assistance
Other (specify)
Banking Information for all Household Members
Please review and check all boxes to confirm you have read all required fields
Name and Address of Bank
Name: ___________________________________________
Type of Account: _________________
(Checking, savings, other-specify)
Address: __________________________________________
Account #: ______________________
Amount: _________________
Name and Address of Bank
Name: ___________________________________________
Type of Account: _________________
(Checking, savings, other-specify)
Address: __________________________________________
Account #: ______________________
Amount: _________________
No Bank Accounts (checking, savings, or other)
Additional Banking Information
Other forms of savings, investments, stocks, bonds, etc. (please specify)
Description: ________________________________________________
Amount: ___________________________________________________
Employment Information
Applicant’s Employer (or most recent employer)
Spouses Employer
Name: ___________________________
Name: ____________________________________________
Address: _________________________
Address: __________________________________________
Phone: ___________________________
Phone: ____________________________________________
I understand that the information I submit is subject to verification by Albany Medical Center/South Clinical
Campus. I certify that the above information is true and correct to the best of my knowledge. Verification will be
done by means including the following; credit bureau inquiries and employment verification.
Signature: __________________________________________
Date: ______________________________________________
Revised 01/01/14
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