Patient Grant Application

Statement of No Income (for Other Household Members)

For use of household members who do not have an income as part of proof of income for grant application.

To be completed as part of Hope Assistance Application if unable to list income sources. Note: This form is for other household members.

Patient Name(Required)

Patient Date of Birth(Required)

Name of Household Member(Required)

Relationship to Patient(Required)

My last working day was(Required)

I recieved my last paycheck on(Required)

I have taken the following steps to try to provide income for myself.(Required)

Social Security benefits

Unemployment benefits

Disability benefits

Medicaid benefits

Other funding benefits

I have not taken any steps to provide income for myself

Select and complete for all that apply:

Social Security Date applied

Social Security Status

If approved, date Social Security benefits start