Application for Financial Assistance

Your Information Will be Kept Confidential

First Name

Last Name

Date

Address

City/State

County

Zip

Phone

Email

Your Sources of Income
Employer

Employer’s Phone Number

Address/City/State/Zip

Job Title

Salary Per Hour

Salary Per Week

Your Spouse’s Sources of Income
Your Spouse’s Name

Employer

Employer’s Phone Number

Address/City/State/Zip

Job Title

Salary Per Hour

Salary Per Week

Other (Social Security, Disability, Federal Assistance, Child Support, Annuities, etc.)

Dependents/Relationship

Please sign below. You must submit all supporting documents to the GVMH Business Office (current income tax return, payroll check stubs for the past 30 days, current Medicaid denial, Social Security, disability income, unemployment or other income and proof of primary residence)
Sign your name

Spouse’s Name

Date

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