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(Data fields preceeded by an asterisk are required)


PATIENT INFORMATION:

  Patient/Applicant Name:   *             Date of Birth:   *               Social Security Number:   *
  Street Address:   *         City/Town:   *         State:   *         Zipcode:   *
  Phone#:   *       Marital Status:   *       Number of Dependent Children:   *        Email:   *

                                              - PATIENT EMPLOYMENT INFORMATION -                                                                     - PATIENT'S SPOUSE EMPLOYMENT INFORMATION -

  Patient Employer....:     Self-employed (Y/N)?:     Spouse Employer...:     Self-employed (Y/N)?:  
  Employer Address..:     Employer Address..:  
  Employer City.........:     Employer City.........:  
  From (year)............:     to (Yr):     From (year)............:     to (Yr):  
  Monthly Gross.....: $     Monthly Gross.....: $  
  Unemployed?.........:     How Long?     Unemployed?.........:     How Long?  

PATIENT'S ADD'L MONTHLY INCOME:                                                                                           SPOUSE'S ADD'L MONTHLY INCOME:

  Social Security Income.............................:   $     Social Security Income.............................:   $  
  Unemployment Compensation..................:   $     Unemployment Compensation..................:   $  
  Worker's Compensation...........................:   $     Worker's Compensation...........................:   $  
  Child Support/Alimony Rec'd....................:   $     Child Support/Alimony Rec'd....................:   $  
  Public Assistance/Housing.......................:   $     Public Assistance/Housing.......................:   $  
  Food Stamps Rec'd.................................:   $     Food Stamps Rec'd.................................:   $  
  Medicare/Medicaid Available...................:   $     Medicare/Medicaid Available...................:   $  
  Grants Rec'd...........................................:   $     Grants Rec'd...........................................:   $  
  Pension Rec'd.........................................:   $     Pension Rec'd........................................:   $  
  Rental Income Rec'd...............................:   $     Rental Income Rec'd...............................:   $  
  Investment Interest/Dividends.................:   $     Investment Interest/Dividends.................:   $  
      Source..:         Source..:  
  Other Income/Benefits.............................:   $     Other Income/Benefits.............................:   $  
      Source1:         Source1:  
      Source2:         Source2:  
      Patient's Total Add'l Monthly Income:   $         Spouse's Total Add'l Monthly Income:   $  
 
      Do any other persons contribute financially to the family? (Y/N)   *       If Yes, Amount?   $     per  

PATIENT AND SPOUSE COMBINED ASSETS:

  Checking Account(s)...................................................Value:   $     Cash on Hand.................................Value: $  
  Bank/Institution:     Stocks / Bonds / Annuities..............Value: $  
  Savings Account(s).....................................................Value:   $     Money Market(s) / CD(s)................Value: $  
  Bank/Institution:     IRA(s) / 401k(s)..............................Value: $  
  Other Asset 1:       Value:   $     Primary Residence.........................Value: $  
  Other Asset 2:       Value:   $     Property (2nd Residence/Land).....Value: $  

PATIENT AND SPOUSE COMBINED DEBTS/EXPENSES:

LIABILITY TYPE OWED TO WHOM MONTHLY PMT BALANCE
LIABILITY TYPE OWED TO WHOM MONTHLY PMT BALANCE
  Mortgage/Rent:   $   $  
  Real Estate:   $   $  
  Properties:   $   $  
  Bank Loans:   $   $  
  Auto Loan 1:   $   $  
  Auto Loan 2:   $   $  
  Credit Card 1:   $   $  
  Credit Card 2:   $   $  
  Credit Card 3:   $   $  
  Credit Card 4:   $   $  
$   $  
$   $  
$   $  
$   $  

PATIENT AND SPOUSE DOCUMENTS TO BE PROVIDED:

If your application for assistance is considered favorably, copies of the following documents may be requested.     Are you willing to provide these?     If No, please explain.

  Last Federal Income Tax Return (Yes/No):   *         If No, why?:  
  Proof of Public Assistance (Yes/No)..........:   *         If No, why?:  
  Bank Statements (last 90 days) (Yes/No)..:   *         If No, why?:  
  Statements of Other Income (Yes/No).......:   *         If No, why?:  

Please answer the following questions:                                                                                 Please write your answers in these text boxes below.

  How did you hear about our Charity Program?  
  What other sources of assistance have you applied for?  
  What other means have you exhausted in trying to raise money?  
  Have you received any additional funds from these resources?  
  Do you have insurance? If so, what kind?  
  How has this medical condition affected your life?   What adjustments are you having to make?  
  What is your treatment plan? Send us a letter from your doctor if you have one.  
  Please provide any additional information that you think the Association needs to know to consider your request:  
  Please provide a specific list of all other charity care for which you have applied:  
  Please describe your personal situation and reasons for requesting assistance.  

This is to advise that I have pursued all other avenues possible for payment, including private insurance, governmental and charitable agencies providing funding and relief from financial obligations: therefore, I hereby request Suwannee River Breast Cancer Awareness Association, Inc. make a determination of my eligibility for their Charity Care Program.   I understand that the information I submit concerning my income, family size, assets, expenses and medical bills is subject to verification by Suwannee River Breast Cancer Awareness Association, Inc.   I also understand that if the information I submit is now or at any time in the future determined to be false, such determination will result in current and/or retroactive denial of Charity Care and I will be liable for charges for services rendered.   I certify that all of the information in this form is true and correct.   Incomplete and fraudulent applications will be denied.   I acknowledge that by submitting this completed application for consideration, I can withdraw said application at any time and the Suwannee River Breast Cancer Awareness Association, Inc. is in no way obligated to distribute any funds for my benefit.

 
  With my electronic signature immediately below, I certify that ALL the information above is understood and correct:  
*
 
  A copy of this application will be emailed to you at the email address you provided above.  

 
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