APPLICATION FOR FINANCIAL ASSISTANCE

Moore County Hospital District

224 East 2nd Street, Dumas, TX 79029
APPLICATION FOR FINANCIAL ASSISTANCE
To process your application, all sections of this form must be completed (front and back Please also include the following documents, if applicable:
- Previous year's tax return
- Two (2) most recent pay stubs for all employed household members
- Most recent bank statements
- Any other income documentation (e.g., Social Security, alimony/child support, unemployment, pension, etc.)
- 2 forms of ID (e.g. driver's license, state issued ID, passport, birth certificate, social security card, green card, work or visitor visa, etc)
SECTION ONE

APPLICANT INFORMATION
Name*

First NameLast Name
Middle Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Phone Number*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do You Have Health Insurance?*

YESNO
IF YES:

Please provide the following:
Insurance Company
Member ID
Group
Attach a copy of your insurance card

If applicable
Cancelof
Have you applied for Medicaid?*

YESNO
IF YES:
Status:

ApprovedDeniedPending
Is this service related to an auto accident?*

YESNO
IF YES:
Insurance Company
Phone Number
Policy Number
SECTION TWO

HOUSEHOLD INFORMATION

List all household members (spouse, children under 18, etc.)

	NAME	DATE OF BIRTH	RELATIONSHIP TO APPLICANT
1
2
3
4
5
6
7
8
9
10

SECTION THREE

INCOME INFORMATION

List monthly gross income for all household members.

	APPLICANT	SPOUSE	OTHER
WAGES / SALARY
SELF-EMPLOYMENT
CHILD SUPPORT / ALIMONY
SOCIAL SECURITY / RETIRMENT
RENTAL INCOME
UNEMPLOYMENT
OTHER INCOME

Explain Other Income
SECTION FOUR

ASSET INFORMATION

Please list all applicable financial accounts.

	APPLICANT	SPOUSE	OTHER
BANK ACCOUNT - CHECKING
BANK ACCOUNT - SAVINGS
HEALTH SAVINGS / FSA
OTHER ASSETS (EXPLAIN)

Explain Other Assets
OPTIONAL DEMOGRAPHIC INFORMATION

This section is voluntary and will not affect your application.
RACE

American Indian / Alaskan NativeBlack / African AmericanWhiteNative Hawaiian / Pacific Islander
ETHNICITY

Hispanic / LatinoNon-Hispanic / Latino
SEX

MaleFemale
Preferred Language

EnglishSpanishOther
APPLICANT CERTIFICATION

By signing below, I certify that the information provided is true and accurate to the best of my knowledge. I understand that providing false or incomplete information may result in denial of financial assistance.
APPLICANT SIGNATURE

Clear
DATE

MonthDayYear
Date
SPOUSE SIGNATURE if applicable

Clear
DATE

MonthDayYear
Date
Need Help? For questions or assistance, contact the Moore County Hospital District Charity Coordinator at 806-934-6060.
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