Financial Assistance Application Step 1 of 6 16% Head of HouseholdName* First Last Date of Birth* Month Day Year Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Employer*Home Phone*Work PhoneCell Phone SpouseSpouse Name First Last No Spouse No Spouse Spouse's Date of Birth Month Day Year Spouse's SSNSpouse's EmployerWork Phone Household InformationPlease include name & date of birth of ALL dependents of household (Full Time Students <25)Family Size*Annual Household Income*Name First Last Date of Birth Month Day Year Name First Last Date of Birth Month Day Year Name First Last Date of Birth Month Day Year Name First Last Date of Birth Month Day Year Name First Last Date of Birth Month Day Year Name First Last Date of Birth Month Day Year Income InformationA copy of your most recent Federal Tax Return is required to be included with your application. If you have other documents of proof of income, please include a copy of them as well. (Social Security, Unemployment, Life Insurance, Pension/Retirement, Child Support, Disability, VA Assistance, Workman’s Comp., Public Assistance, Alimony, etc.)Proof of Income Drop files here or Select files Accepted file types: pdf, jpg, png, gif, Max. file size: 2 MB. REQUIRED: Federal Tax Return (most recent) If you are unable to upload this document, please mail to: Madison County Health Care System Attn: Patient Accounts 300 W. Hutchings St. Winterset, IA 50273AssetsCash on Hand*(including checking)Savings*Stocks/Bonds/Retirement Funds*VehiclesVehicle ModelYearValueVehicle ModelYearValueOther AssetsValueTotal AssetsTotal Asset Value Insurance InformationMedicare #Medicaid #Insurance NamePolicy # Acknowledgement of AccuracyI understand that I assume full responsibility for the accuracy of the statements on this form, and I understand that Madison County Memorial Hospital will use these statements to determine my eligibility for Financial Assistance Program. I HEREBY CERTIFY THAT THE STATEMENTS MADE HEREIN ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.Applicant Signature**RequiredDate* MM slash DD slash YYYY Δ
