Financial Assistance Application Page 4
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4FINANCIAL ASSISTANCE APPLICATION
HOUSEHOLD INCOME & ASSETS
Monthly Income From:
Applicant 1
Applicant 2
Documentation Required:
Name:
_____________
_____________
Gross Wages
$ ___________
$ ___________
Most recent pay stub
Self Employment Income
$ ___________
$ ___________
Tax Return / Estimated Profit & Loss
Rental Income
$ ___________
$ ___________
Tax Return / Estimated Profit & Loss
Unemployment
$ ___________
$ ___________
Check stub, bank statement, online, etc
Workers Compensation
$ ___________
$ ___________
Check stub, bank statement, online, etc
3SquaresVT (food stamps)
$ ___________
$ ___________
Award letter, check stub, bank stmt
Public assistance
$ ___________
$ ___________
Award letter, check stub, bank stmt
Disability
$ ___________
$ ___________
Check stub, bank statement, online, etc
Child support or alimony
$ ___________
$ ___________
Check, garnishment, bank stmt, etc
Social Security
$ ___________
$ ___________
Award letter, check stub, bank stmt
Pension/Retirement Income
$ ___________
$ ___________
Check stub, bank statement, online, etc
Dividend Income
$ ___________
$ ___________
Recent investment statement
Other: _______________
$ ___________
$ ___________
Specify other income
Total:
$ ___________
$ ___________
Cash & Investments:
Applicant 1
Applicant 2
Documentation Required:
Name:
_____________
_____________
Checking account(s)
$ ___________
$ ___________
Bank statement
Savings account(s)
$ ___________
$ ___________
Bank statement
Investment account(s)
$ ___________
$ ___________
Investment/broker statement
Trust Account
$ ___________
$ ___________
Investment/broker statement
Annuities
$ ___________
$ ___________
Investment/broker statement
Other: _______________
$ ___________
$ ___________
Specify
Total:
$ ___________
$ ___________
PLEASE READ CAREFULLY AND SIGN BELOW
I, the undersigned, certify that all information provided in this application is true and complete to best of my
knowledge. I authorize Copley Hospital to verify any of the information provided and any falsification will
result in the denial of my application for assistance. If I receive payment of any kind for the medical services
covered by this financial assistance application, I agree to repay the financial assistance award up to the lesser
of the payment received or assistance awarded. All information provided will remain confidential.
Signature of Applicant ______________________________________ Date ___________
(Parent of minor)
Signature of Co-Applicant ___________________________________ Date ___________
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