Patient Grant Application

Statement of No Income (for Patient Advocate)

If the patient does not have supportive documentation, and the patient does not have income from other sources, please complete the following form:

To be completed by patient advocate as part of Hope Assistance Application if unable to list income sources.

Patient Name(Required)

Patient Date of Birth(Required)

Patient Address(Required)

Patient Phone #(Required)

The patient's last working day was

The patient's last paycheck was received on

The Patient has taken the following steps to try to provide income for themself(Required)

Social Security benefits

Unemployment benefits

Disability benefits

Medicaid benefits

Other funding benefits

None

Select and complete for all that apply:

Social Security Date applied

Social Security Status

If approved, date Social Security benefits start