Foundation for Heart Mountain Free Clinic Financial Assistance Application

Foundation for Heart Mountain Free Clinic

"Neighbors Caring for Neighbors"
The Foundation for Heart Mountain Free Clinic provides financial assistance through a number of programs including First Stop. This application is intended to gain information about your current request and life. This gives us vital information with the intention of giving you the most encompassing access to community resources, direct financial assistance and whole person care. We are a 501(C)3 non-profit. All funding has been donated for the good of the community from generous donors. Your request will be processed as quickly as possible.
APPLICATION FOR FINANCIAL ASSISTANCE
DATE

MonthDayYear
Date
EMAIL:
example@example.com
NAME

First NameLast Name
PHONE
Format: (000) 000-0000.
D.O.B

MonthDayYear
Date
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please select all that apply:

Other
Please select all that apply.

Other

PLEASE LIST ALL MEMBERS OF THE HOUSEHOLD

TOTAL HOUSEHOLD INCOME:
What is your household status? (Check all that apply)

Other
ARE YOU SEEKING ASSISTANCE WITH MEDIACL BILLS?
RENT/MORGAGE AMOUNT:
UTILITES INCLUDED:
PLEASE DESCRIBE WHAT YOU ARE APPLYING FOR. PLEASE BE SPECIFIC AS TO WHAT YOU ARE REQUESTING AND THE DOLLAR AMOUNT YOU ARE REQUESTING:
PLEASE SELECT YOUR ZIP CODE.

Other
HOW LONG HAVE YOU LIVED IN THE BIG HORN BASIN?
HAVE YOU RECEIVED FINANCIAL ASSISTANCE FROM OTHER GROUPS OR CHURCHES?
AMOUNT?
DO YOU HAVE A BUDGET?
DO YOU HAVE TRANSPORTATION?
Please upload ID for all members of the household over 18.

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Please upload income verification for the last 30 days. (This could be paystubs, an awards letter, or bank statements).

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Please upload a copy of your lease of the bill you are requesting assistance with.

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AUTHORIZATION: I, authorize HMFC/First Stop to contact and obtain information from the entities that I am asking for assistance paying. This includes but is not limited to: hospitals, municipalities, electric providers, MDU, and landlords. I understand that HMFC/First Stop is working alongside other local churches and agencies to capture information about people experiencing a need for emergency services, and can share your basic information with other agencies. By applying, you agree to participate in this program.
Signature of applicant
Should be Empty:

Foundation for Heart Mountain Free Clinic