CHC CAP APPLICATION

Proof of income is required to qualify for the Client Assistance Program (CAP Along with this application, you will need to submit a statement of earned income, which may be obtained from the Federal Building on 12th Street. As an alternative, you may submit your most recent income tax return, or your two most recent pay stubs. The information must be updated every six months and anytime your income, household size and/or medical insurance status changes. Whether or not a discount has been applied to your fee(s), you are responsible for full payment of your bill.

Last*

First*

Middle

Date of Birth*

Date

Address*

Phone*

List your name and the name(s) of all individuals who live with you and contribute to or are supported bythe household income:

Name Relationship Age Sex Employer Income

Name Relationship Age Sex Income Employer

Name Relationship Age Sex Employer Income

Other household members not listed above:

Are you currently employed?*

YesNo

Where*

Do you work seasonally?*

YesNo

Where*

How much money do you bring in per month?*

Annually?*

Are you homeless?

YesNo

If you are not working how are you meeting your monthly expenses

Do you currently have health insurance?*

YesNo

If yes, please provide the following insurance information:

Primary Insurance

Address

Phone #

ID #

Group #

List all earnings and benefits that you are receiving in your household:

Wages, salary, and tips before deductions*

$ amount per year

Unemployment Compensation*

$ amount per year

Workers Compensation Benefits *

$ amount per year

Social Security Benefits *

$ amount per year

Supplemental Security Income *

$ amount per year

Public Assistance/ Alaska Temporary Assistance Program/ ATOP Cash Assistance*

$ amount per year

Veteran's Benefits*

$ amount per year

Military Subsidies (BHA, BAS, COLA) *

$ amount per year

Survivor Benefits *

$ amount per year

Pension or Retirement Income *

$ amount per year

Interest *

$ amount per year

Permanent Fund Dividend (PDF) from State of Alaska *

$ amount per year

Tribal, Corporation, or Other Dividends (not including Alaska PFD) *

$ amount per year

Rents Royalties Estates and Trusts*

Educational Assistance for general living expenses Grants Scholarships*

$ amount per year

Alimony*

$ amount per year

Financial Assistance from Outside the Household Foster Care etc*

$ amount per year

Strike Benefits*

$ amount per year

Other Income*

$ amount per year

TOTAL*

Please list two references who are not living with you:

Name

Phone Number

Please enter a valid phone number.

Name

Phone Number

Please enter a valid phone number.

I authorize Continuing Hope Counseling to verify information provided on this application. I also authorize all government agencies, employers, financial institutions and any companies, agencies or persons listed herein to provide information about me to Continuing Hope Counseling . I understand that false statements made on this application are punishable. I certify that the statements regarding the persons and income in my household are true and correct to the best of my knowledge. I further understand if any information is found inaccurate, I may be denied a discount and/or subject to criminal prosecution for knowingly providing false information. I agree to notify Continuing Hope Counseling of all changes in income, address, living arrangements, number of household members and/or other circumstances. I understand that the information given above will be kept confidential, except for the purposes noted above, and not released without my written permission. I also understand that if I do not agree with any decision made concerning this application, I have the right for a review in writing.

Printed Name*

Signature*

Date*

Date

Client Assistance Program Eligibility Form