Wakemed Financial Statement Page 2
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2All Other Income for Patient, Guarantor or Spouse (Check all that apply)
Unemployment
SSI
VA
$
$
$
Worker’s Comp
$
Child Support
$
Investments
$
Alimony
Pension
Retirement
$
$
$
Social Security
Disability
Other
$
$
$
If no income, please explain
Number of Dependents
Please list the names and ages below
Name
Age
Name
Age
Name
Age
Name
Age
Assets
Liabilities
Current Bal
Mo Payment
(attach additional pages if necessary)
Primary Residence
$
Mortgage Balance
$
$
Other Real Estate
$
Mortgage Balance
$
$
Bank Accounts
$
Bank Credit Cards
$
$
Retirement Accounts
$
Other Cards
$
$
Stocks
$
Utilities
$
$
Mutual Funds
$
Rent
$
$
Trust Accounts
$
Other Vehicles
$
$
Other
$
Other
$
$
Cash Value of Life Ins
$
Loans against Life Ins
$
$
Total Assets
$
Total Debt
$
$
Types of Vehicles
Make
Model
Year
Make
Model
Year
Make
Model
Year
Banking Information
Name of Bank
Location
Account Number(s)
Name of Bank
Location
Account Number(s)
Life Insurance Polices
Name of Company
Face Value
Name of Company
Face Value
Name of Company
Face Value
Certification
I certify that the above information is correct to the best of my knowledge. I authorize the release of any of this information
from my employer and or holders of this information, for the purpose of evaluating assistance in the payment of my medical
bills and verification of my income, expenses and assets.
Patient /Guarantor signature
Date
Interviewer’s Signature
Date
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