Do you (Y/N) receive Veteran’s Benefits? Total Household Income Please note your household’s total monthly income from all sources: $____________ Tips $____________ □ Wages □ Self-Employment $____________ Business Profits $____________ □ □ Interest Income $____________ Dividends $____________ □ □ SSI/Social Security $____________ Rental Income $____________ □ □ Child Support $____________ Alimony $____________ □ □ Benefits $____________ $____________ □ Veteran’s □ Worker’s Comp. Unemployment $____________ Food Stamps $____________ □ □ Pension/Retirement $____________ Farm Income $____________ □ □ Insurance/Annuities $____________ Public Assistance $____________ □ □ Trust Income $____________ Other $____________ □ □ Attach copies of the documents listed below for both the patient/guarantor and spouse (please submit only copies; no original documents): Most recent tax return, including W-2 forms and supporting schedules Last 2 pay stubs or a letter from an employer verifying income (include employer’s phone number and address) Bank statements for the past 2 months Written verification of any other income received (e.g. child support, social security, alimony) OR If you have no income, a letter or a comment below from you stating your source for paying living expenses
Do you receive Veteran’s Benefits? (Y/N) Total Household Income Please note your household’s total monthly income from all sources: □ Wages $____________ □ Tips $____________ □ Self-Employment $____________ □ Business Profits $____________ □ Interest Income $____________ □ Dividends $____________ □ SSI/Social Security $____________ □ Rental Income $____________ □ Child Support $____________ □ Alimony $____________ □ Veteran’s Benefits $____________ □ Worker’s Comp. $____________ □ Unemployment $____________ □ Food Stamps $____________ □ Pension/Retirement $____________ □ Farm Income $____________ □ Insurance/Annuities $____________ □ Public Assistance $____________ □ Trust Income $____________ □ Other $____________ Attach copies of the documents listed below for both the patient/guarantor and spouse (please submit only copies; no original documents): Most recent tax return, including W-2 forms and supporting schedules Last 2 pay stubs or a letter from an employer verifying income (include employer’s phone number and address) Bank statements for the past 2 months Written verification of any other income received (e.g. child support, social security, alimony) OR If you have no income, a letter or a comment below from you stating your source for paying living expenses