Patient Grant Application

Statement of No Income

To be completed by patient advocate as part of Hope Assistance Application if patient and/or household member(s) not have supportive documentation, and DO NOT have income from other sources

If you are completing this form for the patient, please leave the “Name of Household member” section blank. If you are completing this form for an other household member who has no income, please complete all fields in the “Name of Household Member” and “Relationship to Patient” section to the best of your knowledge.

Patient Grant Application - Statement of No Income (Current Version)

To be completed by patient advocate as part of Hope Assistance Application if unable to list income sources. If you are completing this form for the patient, please leave the "Name of Household member" section blank. If you are completing this form for an other household member who has no income, please complete all fields in the "Name of Household Member" and "Relationship to Patient" section to the best of your knowledge.

Patient Name(Required)

Patient Date of Birth(Required)

Name of Household Member (if applicable)

Relationship to Patient (if applicable)

Patient Address(Required)

Patient Phone #(Required)

The patient's (or household member) last working day was

The patient's (or household member) last paycheck was received on

The Patient (or household member) 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

No steps taken

Select and complete for all that apply:

Social Security Date applied

Social Security Status

If approved, date Social Security benefits start