Get Financial Assistance Application

Completing the Financial Assistance Application is a vital step in accessing support from Mercy Clinic Business Services. This guide provides a detailed, step-by-step approach to help you successfully fill out the application online.

Follow the steps to complete your application effectively.

1. Press the ‘Get Form’ button to obtain the application form and open it in your designated editor.
2. Begin by entering your personal information in the ‘Applicant Information’ section. You will need to provide your name, social security number, address, birth date, gender, telephone number, and marital status. Make sure to complete each field accurately.
3. List your dependents in the ‘Dependents’ section, including any individual you are responsible for supporting, such as your spouse. Provide their names, birth dates, and your relationship to them.
4. In the ‘Employment’ section, indicate your current employment status. If employed, include your employer’s name, address, phone number, and length of employment. Select the appropriate option if you are retired or unemployed.
5. Provide detailed information about your monthly income in the ‘Monthly Income’ section. Document all sources of income for yourself and other household members, including employment, social security, pensions, and child support. Remember to include total income calculations.
6. Complete the ‘Monthly Fixed Expenses’ section by listing your regular monthly expenses, such as rent or mortgage payments, food, utilities, and other relevant costs.
7. In the ‘Banking Information’ section, provide the name of your bank, along with account balances for both checking and savings accounts. Indicate if you have other investments.
8. Fill out the ‘Property / Other Assets’ section with details on any mortgages, vehicles, or other properties you own. List the estimated value and unpaid balance for each.
9. You may also include any additional information that you think is important in the final section. Indicate whether you have applied for Title XIX, Social Security, or Disability benefits, and note the outcomes.
10. Finally, review all provided information, certify its accuracy by signing the application, and indicate the date. Ensure you have included required documentation of household income before submission.
11. After completing the application, you can save your changes, download a copy for your records, print the form, or share it as needed.

Take the next step and complete your Financial Assistance Application online today.