Eyeglass Assistance Application
A confidential request for help with prescription eyeglasses
We are glad you reached out.
Please provide your best answers. If something does not apply, enter N/A. We will contact you if clarification is needed.
1. About You
FULL NAME
First Name
Last Name
DATE OF BIRTH
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
TELEPHONE
Format: (000) 000-0000.
EMAIL
example@example.com
ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
MARITAL STATUS
Married
Widowed
Divorced
Single
2. Your Household
NUMBER OF ADULTS
NUMBER OF CHILDREN / DEPENDENTS
HOUSEHOLD MEMBERS - LIST EACH PERSON'S NAME, AGE, AND RELATIONSHIP TO YOU
SPOUSE / OTHER ADULT EMPLOYER OR INCOME SOURCE
MONTHLY INCOME
3. Employment and Household Income
Current employment status:
Employed
Self-employed
Not employed
Retired / disability
CURRENT EMPLOYER / COMPANY
EMPLOYER TELEPHONE
Format: (000) 000-0000.
EMPLOYER ADDRESS
YEARS EMPLOYED
YOUR GROSS INCOME / MONTH
YOUR NET INCOME / MONTH
OTHER HOUSEHOLD INCOME / MONTH
TOTAL GROSS HOUSEHOLD INCOME / MONTH
TOTAL TAKE-HOME HOUSEHOLD INCOME / MONTH
IF NOT EMPLOYED: MOST RECENT EMPLOYER AND REASON EMPLOYMENT ENDED
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Thank you for sharing this information.
These questions help us understand your household financial picture and vision needs.
4. Financial Snapshot
HOUSING STATUS
Rent
Own home
MONTHLY RENT OR MORTGAGE
ESTIMATED HOME VALUE
VEHICLE MAKE, MODEL AND YEAR
ESTIMATED VEHICLE VALUE
VEHICLE PAYMENT / MONTH
BANK OR FINANCIAL INSTITUTION
CURRENT CHECKING BALANCE
TOTAL SAVINGS / CDS
OTHER SIGNIFICANT ASSETS OR AVAILABLE FUNDS
5. Essential Monthly Expenses
HOUSING
UTILITIES
FOOD AND HOUSEHOLD NEEDS
TRANSPORTATION / VEHICLE
MEDICAL / PRESCRIPTIONS
DEBT / REQUIRED PAYMENTS
6. Vision Care
Have you worn prescription glasses before?
Yes
No
IF YES, HOW MANY YEARS?
APPROXIMATE DATE OF LAST EYE EXAM
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
EYE DOCTOR / CLINIC
DOCTOR / CLINIC TELEPHONE
Format: (000) 000-0000.
DOCTOR / CLINIC ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
7. How Can We Help?
Briefly explain what is making it difficult to obtain the glasses you need and anything else we should consider.
I certify that the information in this application is true, complete, and accurate to the best of my knowledge.
I understand that false or misleading information may result in denial of my application or assistance.
APPLICANT SIGNATURE
DATE
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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