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Get Duke University Health System Financial Hardship Form

Duke University Health System Financial Hardship Form A. - FAMILY INFORMATION 1. First name middle initial please print Last name please print 2. Street address 3. City state zip code 4. Social security number 5. Day phone area code 6. Evening phone area code 7. Employed 8. Name of employer/company 9. Employer/company street address 11. How long have you worked here 12. Number of dependents B. - FINANCIAL DATA Patient / Guarantor 1 Spouse / Guarantor 2 YESNOSELF Years Months MONTHLY INCOME 1. Gross salaries wages before taxes 2. Business Income 3. Rental Income 4. Investment Income 5. Income from Estates/Trusts 6. Alimony Income 7. Child Support 9. Aid to Dependant Children 10. Public Assistance Income 11. Other Income list amount source lines 11-12 13. Total Income All Sources ASSETS 1. Cash on hand 2. Checking Account s balance 3. Savings Account s balance 4. Mutual Funds current value 5. Stocks current value 6. Bond s current value 7. Home - assessed value 8. Rental property assessed value 9. Business property assessed value 10. Automobile s -estimated value List make model year below Auto 1. 11. Recreational Vehicle s estimated value 12. Boat s estimated value 1 of 1 13. Cash value of life insurance 15. Total Assets Comments Required Documentation include copies for yourself and spouse/guarantor 1 Attach copies of your most recent tax return including W-2 forms and supporting schedules. 2 Last 2 pay stubs 3 written verification of any other income received e*g* child support social security alimony. OR 1 A letter from an employer verifying income include employer s phone number and address. 2 A letter from you stating your source for paying living expenses if you have no income. Mail documentation to PRMO Self Pay 5213 South Alston Ave Durham N*C. 27713 I hereby acknowledge that the above information is true and accurate to the best of my knowledge. I further grant the Health System authorization to verify any or all information given and also authorize a consumer credit report if necessary. Date FOR OFFICE USE ONLY ACCOUNT INFORMATION Entity PDC DRH RCH DUH Account/Invoice Number s Balance Due Date s of Service CHARITY DETERMINATION Approved Denied By Date 2 of 2. Street address 3. City state zip code 4. Social security number 5. Day phone area code 6. Evening phone area code 7. Employed 8. Name of employer/company 9. Employer/company street address 11. How long have you worked here 12. Employed 8. Name of employer/company 9. Employer/company street address 11. How long have you worked here 12. Number of dependents B. - FINANCIAL DATA Patient / Guarantor 1 Spouse / Guarantor 2 YESNOSELF Years Months MONTHLY INCOME 1. Number of dependents B. - FINANCIAL DATA Patient / Guarantor 1 Spouse / Guarantor 2 YESNOSELF Years Months MONTHLY INCOME 1. Gross salaries wages before taxes 2. Business Income 3. Rental Income 4. Investment Income 5. Income from Estates/Trusts 6. Gross salaries wages before taxes 2. Business Income 3. Rental Income 4. Investment Income 5. Income from Estates/Trusts 6. Alimony Income 7. Child Support 9. Aid to Dependant Children 10. Public Assistance Income 11. Other Income list amount source lines 11-12 13. .

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