**INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED** APPLICATIONS MUST BE RECEIVED BY THE LAST FRIDAY OF EACH MONTH FOR CONSIDERATION THE FOLLOWING MONTH. Original Applications Each Month only (all pages must be original no copies) – – please do not resubmit previous month’s applications. Date Today’s Age Patient’s Name Name Age Applicant’s Applicant’s Applicant’s Phone number ( ) SS# Address Applicant’s City State Zip Diagnosis and condition of patient ____________________________________________________________________________ relationship to Patient Applicant’s No. living in household Ages of dependent children in household Others financially dependent on applicant Is the patient currently: and working full time □ employed on FMLA/Disability/Leave □ employed but Time Employed: □Full Time □Part □Unemployed □Disabled APPLICANT SPOUSE OTHER PERSONS Employer Type of Work ASSETS (List CURRENT VALUE): Checking Accounts $ Savings Accounts $ Other Investments/ Liquid Accts $
**INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED** APPLICATIONS MUST BE RECEIVED BY THE LAST FRIDAY OF EACH MONTH FOR CONSIDERATION THE FOLLOWING MONTH. Original Applications Each Month only (all pages must be original – no copies) – please do not resubmit previous month’s applications. Today’s Date Patient’s Name Age Applicant’s Name Age Applicant’s Applicant’s Phone number ( ) SS# Applicant’s Address City State Zip Diagnosis and condition of patient ____________________________________________________________________________ Applicant’s relationship to Patient No. living in household Ages of dependent children in household Others financially dependent on applicant Is the patient currently: □ employed and working full time □ employed but on FMLA/Disability/Leave Employed: □Full Time □Part Time □Unemployed □Disabled APPLICANT SPOUSE OTHER PERSONS Employer Type of Work ASSETS (List CURRENT VALUE): Checking Accounts $ Savings Accounts $ Other Investments/ Liquid Accts $
aahc-application-final2018.docx