Friends in Pink Free Mammogram Application

Name*

Address*

City*

State*

Zip*

Phone Number/s*

Date of Birth*

Date

Social Security Number

Marital Status

SingleDivorcedMarriedWidowed

Name of Doctor

Doctors Address

Doctor's Phone Number

No of people in Household*

No of children under 18*

RaceEthnicity

Please provide the following information completely and accurately. Information is subject to verification.

Are you employed?*

YesNo

Employer Name

Are you insured?*

YesNo

Insurance Name

Monthly Income

Gross Income(before taxes)

Other Household Gross Income

Investment Income

Rental Property Income

Unemployment Income

Other Income

Total Income

Assets

Value of Residence

Bank Account Balances(ALL)

Auto Value

Boat Value

Recreational Vehicle Value

Other Assets

Total Value Assets

Monthly Expenses

Rent/Mortgage

Property & Health Insurance Expense

Utilities Expense

Food Expense

Auto Payments (Loan &Insurance)

Medical & Prescription Expense

Other Expenses

Total Expenses

Liabilities

Equity Loan

Balance of Mortgage

Credit Card Debt

Auto Loan Balance

Other Loan Balances

Real Estate Taxes

Estimated Medical Bills

Other Liabilities

Total of Liabilities

I hereby apply for financial assistance from Friends In Pink, Inc. I certify the information provided above is an accurate and a true representation of my financial information. I also certify that I have no additional insurance coverage other than stated above. I understand that providing false information will result in denial of assistance from Friends In Pink, Inc. I understand that my credit report will be used to verify this information. My failure to follow through with the application process or take actions to reasonably complete "Patient Eligibility Requirements" may result in denial of this application.

Patient Signature*

Date*

Date

Friends In Pink Questionnaire

Mammography Financial Assistance Application