| Patient
Name: ____________________________________ |
| Account
Number (s): ______________________________ |
| NET MONTLY INCOME:
Please indicate all sources of income. |
| A) Patient/Guarantor* |
$ ____________________ |
| B) Spouse* |
$ ____________________ |
| C) Other Income* |
$ ____________________ |
| TOTAL NET MONTHLY INCOME: |
$ ____________________ |
| MONTHLY EXPENSES :
Please indicate your average monthly
expenses for the following items: |
| D) Food |
$ ____________________ |
| E) Utilities |
$ ____________________ |
| F) Auto, Gas |
$ ____________________ |
| G) Telephone |
$ ____________________ |
| H) Childcare |
$ ____________________ |
| I) Other |
$ ____________________ |
| J) Other |
$ ____________________ |
TOTAL |
$ ____________________ |
CREDITORS :
Please indicate the amount of all monthly
payments and to whom the payment is
made. |
| K) Rent/Mortgage* |
$ ____________________ |
| L) Insurance (Auto)* |
$ ____________________ |
| M) Insurance (other)* |
$ ____________________ |
| N) Other payment * |
$ ____________________ |
| O) Other payment * |
$ ____________________ |
| P) Other payment * |
$ ____________________ |
| • DOCUMENTATION
REQUIRED |
