Application for Charity Care Assistance The Faulk Foundation Applicant Name:
Last
First
Address:
_______________________________________ Do you Rent: _____ _______________________________________
MI
Or Own: _____
_______________________________________ Number of months as a resident at this address:
_________________________
Phone Number: _________________________
Social Security Number:
_________________________
Date of Birth of Applicant: _________________________
Why are you seeking assistance from the Faulk Foundation?
Please indicate what you are seeking assistance with: Food: _____ Bills: _____ Clothing: _____ Medicine: _____ Other (please specify) : _________________________
Furniture: _____
Are you a U.S. Citizen?
_______ Yes
_______ No
Do you have minor children (under 18)?
_______ Yes
_______ No
Do they live with you?
_______ Yes
_______ No
Are they your birth/legally adopted children?
_______ Yes
_______ No
Do you have medical insurance?
_______ Yes
_______ No
Are you a veteran?
_______ Yes
_______ No
Are you on disability?
_______ Yes
_______ No
If Yes, how Long? _______________
FAMILY MEMBERS LIVING WITH YOU Spouse: ______________________________
If any of the dependents living with you are employed, please fill out the
Child:
_____________________ Age: ____
form on Page (5)
Child:
_____________________ Age: ____
Child:
_____________________ Age: ____
Child:
_____________________ Age: ____
Other: ______________________________ Other: ______________________________ SOURCE OF INCOME: Head of Household Current Employer:
_____________________
Spouse Current Employer:
Occupation:
_____________________
Occupation:
_____________________
Address:
_____________________
Address:
_____________________
Phone Number:
_____________________
Phone Number:
_____________________
Other Employers:
_____________________
Other Employers:
_____________________
Address:
_____________________
Address:
_____________________
Phone Number:
_____________________
Phone Number:
_____________________
_____________________
Please list ALL employers. If additional space is required, please use the form on Page (5). Ph: (713) 358-6327 www.faulkfoundation.org Fax to (281)768-6582
[1]
The Faulk Foundation 6135 Northdale Houston, TX 77087
Application for Charity Care Assistance The Faulk Foundation INCOME (Monthly Amount)
EXPENSES (Monthly Amount)
Gross
Net
Rent/Mortgage
Head of Household
$_____________
$_____________
Spouse
$_____________
$_____________
Homeowner’s Insurance Property Tax
Dependents
$_____________
$_____________
$______________________ $______________________ $______________________
Electric
$______________________
Gas/Propane
$______________________ $______________________
Public Assistance
$_____________
$_____________
Water
Food Stamps
$_____________
$_____________
Telephone
$______________________
Social Security
$_____________
$_____________
Food
$______________________ $______________________
Unemployment
$_____________
$_____________
Car Payment
Strike Benefits
$_____________
$_____________
Car Insurance
$______________________
Gasoline
$______________________
Worker’s Compensation $_____________
$_____________
Child Support
$______________________
Child Support
$_____________
Child Care
$______________________
Medical Cost
$______________________
$_____________
Military Allotments
$_____________
$_____________
Pharmacy Cost
$______________________
Pensions
$_____________
$_____________
Clothing
$______________________
Income from: CD’s, Rent, Dividends Interest
TOTAL
Charge Cards (Total per month)
$_____________
$_____________
$_____________
$_____________
$______________________
Loans
$______________________ Medical Insurance $______________________ Life Insurance $______________________ Other: _______________ $______________________ TOTAL $______________________
ASSETS
VEHICLES
Cash on Hand
$______________________
Checking Account
$______________________
Savings Account
$______________________
IRA’s
$______________________
Investments Stocks/Bonds
$______________________
Make of Motorcycle Make of Boat
Land/Property Other than home you live in
Estimated Value
Make/Model of Auto #1 ________________ $_____________ Make/Model of Auto #2 ________________ $_____________
$______________________
Recreational Vehicle
________________ $_____________ ________________ $_____________ ________________ $_____________
Car/Vehicle Insurance
$_____________
If you have no income, please explain how you have been meeting your needs: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________
Ph: (713) 358-6327 www.faulkfoundation.org Fax to (281)768-6582
[2]
The Faulk Foundation 6135 Northdale Houston, TX 77087
Application for Charity Care Assistance The Faulk Foundation
MEDICAL INSURANCE/BENEFITS Insurance Company: _________________________ Person Covered
Source & Type
ID/Case Number
Effective Date
_________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________
Are any members of your family unable to work _______ Yes _______ No due to age, illness, or injury? Are any of those family members minor _______ Yes _______ No children (under 18)? If yes, please list these illnesses: ____________________________________ Are you currently seeking treatment with a physician or hospital? Are you or any member of the household pregnant?
_______ Yes
_______ No
_______ Yes
_______ No
MEDICAL BILLS Total Owed
Monthly Payment
$_____________
$_____________
Medicines: $_____________
$_____________
Hospital:
$_____________
$_____________
Other:
$_____________
$_____________
Doctors:
Are you currently applying for Medicaid Benefits?
_______ Yes _______ No
Are you a member of an Employer Benefit Plan?
_______ Yes _______ No
Have you applied for assistance from your county hospital/indigent program? _______ Yes _______ No Is your physician donating his/her services?
_______ Yes _______ No
Is anyone assisting you with payment of your hospital bills?
_______ Yes _______ No
Who is assisting you?
______________________
How much assistance are you receiving?
______________________
List any other information you feel would be helpful to us in determining your eligibility for assistance. __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________
Ph: (713) 358-6327 www.faulkfoundation.org Fax to (281)768-6582
[3]
The Faulk Foundation 6135 Northdale Houston, TX 77087
Application for Charity Care Assistance The Faulk Foundation OTHER SUPPORTING DOCUMENTS REQUIRED ______ Bank Statements (All Accounts) ______ Investment Account Statements ______ Pay Stubs (reflecting last three (3) months pay or letter from employer) ______ Latest Federal Income Tax Return filed (all pages) ______ Medicaid Denial (if applicable) ______ Employer Benefit Plan Description
In order to be eligible, a completed document AND all required documents must be provided, in addition to meeting all eligibility criteria.
You DO have my permission to use my and/or my child’s name, photographic or video image in promotion of The Faulk Foundation and its fundraising activities, newsletter, website, email, or any other promotional activities ______(initial).
I understand that the information that I submit is subject to verification by the Faulk Foundation, and hereby give the Faulk Foundation permission to obtain information necessary from, but not limited to, the following sources: banks, credit unions and other financial institutions, employers, medical providers, landlord, and other agencies such as the Department of Social Services, the Department of Labor, the Social Security and Veteran’s Administration, and the Immigration and Naturalization Service. I am aware that this information will be used to determine my eligibility for charity assistance and that the falsification of information in this application may result in denial of charity care assistance. I certify that the above information is true and correct. I agree to inform the Faulk Foundation within 30 days of any changes in income, expenses, insurance status or family status. ___________________________________________ Signature of Applicant
_____________________ Date
___________________________________________ Printed Name
Ph: (713) 358-6327 www.faulkfoundation.org Fax to (281)768-6582
[4]
The Faulk Foundation 6135 Northdale Houston, TX 77087
Application for Charity Care Assistance The Faulk Foundation
If Necessary: If any of the dependents living with you are currently employed, please provide their occupations, incomes, and how long they have been employed below. Name: Relation to Applicant: Current Employer:
_____________________ _____________________ _____________________
Name: Relation to Applicant: Current Employer:
_____________________ _____________________ _____________________
Occupation:
_____________________
Occupation:
_____________________
Address:
_____________________
Address:
_____________________
Phone Number:
_____________________
Phone Number:
_____________________
Other Employers:
_____________________
Other Employers:
_____________________
Address:
_____________________
Address:
_____________________
Phone Number:
_____________________
Phone Number:
_____________________
Please list ALL employers. If additional space is required, please attach a separate sheet of paper.
HOW DID YOU HEAR ABOUT THE FAULK FOUNDATION? ____________________________________________________________ ____________________________________________________________
Applications should be mailed to the following address: The Faulk Foundation 6135 Northdale Houston, TX 77087 (713) 359-6196
Applications may also be submitted via: Email to
[email protected] Faxed to (281) 768-6582
Ph: (713) 358-6327 www.faulkfoundation.org Fax to (281)768-6582
[5]
The Faulk Foundation 6135 Northdale Houston, TX 77087
