Financial Assistance Program – Online Application

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Head of Household
Name*
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 Phone
- Cell Phone

Household Information
Please 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 Information
A 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

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 50273
Assets
- Cash on Hand*
  (including checking)
- Savings*
- Stocks/Bonds/Retirement Funds*
Vehicles
- Vehicle Model
- Year
- Value
- Vehicle Model
- Year
- Value
- Other Assets
- Value
- Total Assets
- Total Asset Value

Acknowledgement of Accuracy
I 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*
Date*
MM slash DD slash YYYY

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Head of Household