Financial Statement - Stonewall Jackson Memorial Hospital

Account Number:
Patient Name:
Date of Birth:
Address:
Financial Statement
Responsible Party:
Relationship to Patient:
Date:
Telephone Number:
1)
2)
3)
4)
5)
NAME
Please complete all categories for all members in your household (including yourself).
RELATIONSHIP DATE OF BIRTH EMPLOYED EMPLOYER'S NAME
YES/NO
ADDRESS/TELEPHONE
OTHER HOUSEHOLD INCOME: (including child support, rental income, etc.)
If you are unemployed, when did you become unemployed, and why?
Explain the services that you received or are needing at SJMH:

MONTHLY EXPENSES
Do you own your home? Yes/No Do you rent your home? Yes/No
Mortgage Amount:
Monthly Rent Amount:
Monthly Payment:
If you do not own or rent your home, where do you live?
What is the value of your home?
Expense Monthly Payment
Balance Expense Monthly Payment Balance
Electric
Cell Phone
Water
Vehicle insurance
Telephone
Vehicle Payment
Trash
Doctor/Hospital
Cable/Satellite
Prescriptions
Gas/Propane
Life Insurance
Credit Cards 1)
2)
3)
Items Purchased:
Items Purchased:
Items Purchased:
Loans 1)
Reason:
2) Reason:
3) Reason:
Do you receive food stamps? Yes/No
How Much?
List any other monthly expenses:
**If additional space is needed to list other creditors or bills, please list them on a separate sheet of paper.
All parts of this form must be completed or your application will not be considered.
I attest that the information contained on this form is true and correct to the best of my knowledge. Furthermore, should any monetary
settlement be retrieved from any source relevant to services provided at Stonewall Jackson Hospital said funds shall be distributed to
Stonewall Jackson Memorial Hospital for payment of accounts written off as a result of this application.
Signature Date Witness Date