Please describe your need(s) below:Lodging: Description of lodging needs Utilities: Description of utility bills/needs In-home support: Description of in-home support needs If applicable, number of treatments requested: Number of in-home treatments Transportation: From: Transportation starting address To: Destination Frequency: Frequency of transportation needs Other transportation options exhausted: Family/friends: Yes No Public transportation: Yes No Other: Other transportation options Total dollar amount of bills and services: Total dollar amount If this is a reoccurring bill, are there plans for paying in the future? Plans for paying future, recurring bills Consequences if no financial assistance received for this bill or service? Consequences if no financial assistance for this bill or service
Total monthly expenses: Total monthly expenses Mortgage/rent: Mortgage/rent amount Phone: Monthly phone bill amount Food: Monthly food/grocery cost Auto: Monthly car payment/maintenance cost Gas: Monthly cost for gas Car insurance: Monthly premium Water/sewer: Monthly cost Electric: Monthly cost Pets: Monthly cost for pets Other: Other monthly costs
Gross monthly income (before taxes):Self: Gross monthly income Spouse: SpouseOther income: Other income Sources of other income: Sources of other income
Family/friends who might be able to loan money:Yes NoComment: Savings, IRA or retirement plans from which applicant can borrow/access money?Yes No Comment: Referral to financial counselor?Yes NoIf yes, Date: If Yes, Date Other resources/agencies referred to or utilized?
Has insurance been explored to cover expense? Yes No Comment: Primary/secondary insurance: Medi-Cal eligible? Yes NoComment:
I understand that aid is limited by the status of the funds and is available only after I have made use of all other resources available to me. I also understand that I may be contacted by Adventist Health Sonora and that my request will be handled in a confidential manner. My signature verifies that the information I have supplied is accurate.Signature