Patient Grant Application

Statement of Income Verification

To be completed as part of the HOPE Assistance Application if income is received in cash and standard income documentation is unavailable. This form may be completed by the patient or a member of the patient’s household.

NCS HOPE Foundation — Statement of Income Verification

Patient Name(Required)

Patient Date of Birth(Required)

Patient Address(Required)

Patient Phone #(Required)

Income Information

This form certifies that the income listed below is received in cash and is not documented through pay stubs, tax returns, or direct deposits. This income is contributed by either the patient or a member of the patient’s household and is used to support the household's living expenses.

Name of Person Earning Income(Required)

Today's Date(Required)

Relationship to Patient(Required)

Address (if different from above)

Type of Work or Services Provided:(Required)

(e.g., cleaning, childcare, construction, freelance labor, etc.)

Monthly Gross Income Amount ($):(Required)

Date Income Started(Required)

Date Income Ended (if applicable):

Printed Name of Person Completing Form(Required)

Today’s Date(Required)