Financial Assistance

Financial Assistance

APPLICANT/RESPONSIBLE PARTY (Last, FIrst, M.I.)*

Applicant SSN*

Does the Applicant Have a Spouse?*

Yes

SPOUSE'S NAME (If Applicable; Last, First, M.I.)

Spouse's SSN

Address*

City, State*

Zip Code*

Phone Number*

Email Address*

Number of Adults in Household*

Number of Minors in Household*

Time at Present Address (YEARS, MONTHS)*

Own or Rent?*

Own

Rent

Demographics

Is the Applicant Currently Working?*

Select or enter value

Applicant Employer

Applicant Employer Phone

Applicant Occupation

Applicant Time at Current Employer

Applicant Current Hourly Wage

Is the Spouse Currently Working (If Applicable)?

Select or enter value

Spouse's Employer

Spouse's Employer Phone

Spouse's Occupation

Spouse's Time at Current Employer

Spouse's Hourly Wage

Income

Applicant Employment Income

Applicant Retirement/Pension Income

Applicant Social Security Income

Applicant Worker's Compensation Income

Applicant Unemployment Income

Applicant Disability Income

Applicant Veteran's Benefits Income

Applicant Public Assistance Income

Applicant Interest Dividends Income

Applicant Rental Income

Applicant Child Support Income

Applicant Alimony Income

Spouse's Employment Income

Spouse's Retirement/Pension Income

Spouse's Social Security Income

Spouse's Worker's Compensation Income

Spouse's Unemployment Income

Spouse's Disability Income

Spouse's Veteran's Benefits Income

Spouse's Public Assistance Income

Spouse's Interest Dividends Income

Spouse's Rental Income

Spouse's Child Support Income

Spouse's Alimony Income

Assets

Checking Account Bank Name

Checking Account Balance

Savings Account Bank Name

Savings Account Bank Balance

Certificate of Deposits (CD) Bank Name

Certificate of Deposits (CD) Balance

Combined Stocks and Bonds Balance

Combined IRA Balance

Motor Vehicle 1 Year/Make/Model

Motor Vehicle 1 Loan Balance

Motor Vehicle 1 Assessed Value

Motor Vehicle 2 (If Applicable) Year/Make/Model

Motor Vehicle 2 (If Applicable) Loan Balance

Motor Vehicle 2 (If Applicable) Assessed Value

Rec Vehicle (If Applicable) Year/Make/Model

Rec Vehicle (If Applicable) Loan Balance

Rec Vehicle (If Applicable) Assessed Value

Name of Mortgage Company

Mortgage Balance

Assessed Value of Home

Monthly Expenses

Enter $0 if not applicable.

Mortgage or Rent Expense*

Renters or Home Insurance Expense*

Phone Expense*

Cable Expense*

Internet Expense*

Electiric Expense*

Natural Gas Expense*

Water/Sewer Expense*

Food Expense*

Car Payment Expense*

Car Insurance Expense*

Rec Vehicle Expense*

Alimony Expense*

Child Support Expense*

Child Care Expense*

Other Expenses?*

Yes

Other Expense 1 Desc

Other Expense 1 Amount

Other Expense 1 Monthly Payment

Other Expense 2 Desc

Other Expense 2 Amount

Other Expense 2 Monthly Payment

Other Expense 3 Desc

Other Expense 3 Amount

Other Expense 3 Monthly Payment

Other Expense 4 Desc

Other Expense 4 Amount

Other Expense 4 Monthly Payment

Other Expense 5 Desc

Other Expense 5 Amount

Other Expense 5 Monthly Payment

Any Other Medical Expenses?*

Yes

Medical Expense 1 Desc

Medical Expense 1 Amount

Medical Expense 1 Monthly Payment

Medical Expense 2 Desc

Medical Expense 2 Amount

Medical Expense 2 Monthly Payment

Medical Expense 3 Desc

Medical Expense 3 Amount

Medical Expense 3 Monthly Payment

Medical Expense 4 Desc

Medical Expense 4 Amount

Medical Expense 4 Monthly Payment

Medical Expense 5 Desc

Medical Expense 5 Amount

Medical Expense 5 Monthly Payment

Documentation Upload

Please Upload a Copy of Last Year's Tax Return, Most Recent PayStub, and Most Recent Bank Statement

Drag and drop files here or

Authorization

By typing your name below, you authorize American Pain Consortium to obtain an asset verification. This is deemed necessary to complete the Financial Hardship Application. This also is your certification that the information submitted is correct and authorize you to obtain relevant credit information.

Name (First, M.I., Last)*

Today's Date*

Spouse's Name (First, M.I., Last)

Send me a copy of my responses

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