Woods & Water Medical Center * Financial Application

Patient Name Patient Account Number

Name Spouse
Z
i
Address City State p
Time at Present Address: Years Months Rent Own

Phone Number Number in household member (Including self & spouse)

Monthly GrossSelf Monthly Gross-Spouse

Income represents total cash receipts from all sources before taxes. Use separate sheet for multiple employers.

Gross Income $ $

Social Security $ $

Public Assistance $ $

Rental Income $ $

Pension/Retirement $ $

Veterans Benefits $ $ Spouse

From To From To
Unemployment Date Date $ Date Date $
From To From To
Workers Comp. Date Date $ Date Date $

Child Support $ $

Disability $ $

Other (Identify) $ $

Total $ $

Employer

Business Address

Business Phone ( ) ( )

Occupation

How long employed

Wages: Hourly Wage $ Hours/Week Wages: Hourly Wage $ Hours/Week

 Assets/Savings/Property
Location Amount/Value

Checking

Savings

Certificate of Deposit (CD)

Stocks/Bonds
Retirement/IRA/401K/Other

Motor Vehicle Year/Make/Model Value Loan Balance

Motor Vehicle Year/Make/Model Value Loan Balance

Recreational
Year/Make/Model Value Loan Balance
Vehicles (boats,
snowmobiles, ATVs,
Year/Make/Model Value Loan Balance
etc.

Primary Homestead Loan Balance $ Fair Market Value

Real Estate Loan balance $ Fair Market Value

Monthly Expenses
Mortgage/Rent Child Care Cable TV/Satellite Phone Bill

Auto Food Electric Health Insurance

Heat/Fuel Auto Insurance Transportation Child Support Payments

Property Taxes (Annual) Medications

Charge Accounts/Other Expenses/Medical Bills

Creditor Name Address Balance Monthly Payment

I certify that the above information is true to the best of my knowledge and belief. This information is confidential and may
be used by Woods & Water Medical Center to determine my current ability to pay my medical debts. Woods & Water Medical
Center routinely requests Credit Bureau reports to assist in its determination.

Signature Date

Witness Date