Statement Of Financial Obligations
Before completing and signing this statement, please review all your debts carefully. Be sure that you are disclosing all debts of any kind and that the facts stated in this statement are complete and correct.
Responsible Person: ____________________________________ Age: ___________________
Address: _______________________________________________________________________
Spouse: ____________________________________________ Age: ______________________
Patient Name: ____________________________________ Age: ________________________
Address: ____________________________________________ Phone: ___________________
____________________________________________
Number of Family Members: ___________________________ Ages: ______________________
INCOME
Employer: ____________________________ Address: _________________________________
Spouse Employer: ______________________ Address: _________________________________
Monthly Income: Wages (Yours) $___________________
Wages (Spouse) $___________________
Unemployment $___________________
Disability $___________________
Food Stamps $___________________
General Assistance $___________________
Other $___________________
Total Monthly Income $___________________
Note
Copies of supporting documents preferred to support income include:
Last year income tax return
Last month bank statement
Last 2 pay stubs
Credit Report Authorization/signed and dated
If no reportable income, please submit a letter of reference from a person of the community who is aware of your financial status such as clergy, business person or physician.
DEBTS AND OBLIGATIONS
Home Own ( ) Rent ( )
Creditor Payment Balance
Mortgage/ Rent ____________________ $________________ $____________________
Utilities __________________________ ________________ ____________________
Vehicle Loan _____________________ ________________ ____________________
Life/ Medical Ins __________________ ________________ _____________________
Credit Cards ______________________ ________________ _____________________
____________________ ________________ _____________________
Other Debts ______________________ ________________ _____________________
______________________ ________________ _____________________
Other Medical Bills
_______________________ ________________ _____________________
_______________________ ________________ _____________________
_______________________ ________________ _____________________
Food ________________________ ________________ _____________________
Other (please specify) _______________ ________________ _____________________
________________ ________________ _____________________
_________________ ________________ _____________________
Total Debts and Obligations $________________ $____________________
ASSETS
House/ Property/ Furniture Assessed Value $ _____________________
Checking/ Savings Accounts Balance $ ____________________
Life Insurance Policies Cash Value $ ____________________
Vehicles/ Boat/ RV’s Year & Model Value
__________________________ $ _______________
__________________________ $ _______________
__________________________ $ _______________
__________________________ $ _______________
__________________________ $ _______________
Applicant Signature____________________________________________________
Co-Applicant Signature____________________________________________________
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