Please help us to assist you in determining your eligibility for Charity Assistance by answering the following questions:

1. How many people are in your family?
   
   
2. Are any members of your family unable to work due to age, illness or injury?
   
   
3. What are the ages of the family members in your household?
   
   
4. How many dependents are being supported in your family?
   
   
5. What are the ages of the dependents? If any of the dependents are working, what are their occupations and incomes? How long have they been employed?
   
   
6. Is the head of the household widowed or divorced?
   
   
7. If divorced, what is the amount of alimony and/or child support received/paid?
   
   
8. Are there any other medical or financial problems within the family?
   
   
9. What are the family's assets, e.g., equity in home, equity in automobile?
   
   
10. Has the patient filed for bankruptcy recently?

The responses to these questions can be used in addition to the family income criteria.

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