Hughes Family Application

Applicant Information

Name*

First

Last

Date of birth*

Day Phone*

Evening Phone*

Email*

Current Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Number of children living at home

Children's Ages

Do you have (check all that apply)

Medical Insurance

Medicaid

Medicare

Liberty Hospital Employment Information

Supervisor*

Department*

Position*

Full Time

Part Time

Date of Hire*

Spouse/Partner Employment Information

Name*

First

Last

Employer

Position

Expenses – Monthly Household

Rent/Mortgage

Utilities

Insurance

Telephone

Food

Gasoline (vehicles)

Other

Expenses – Outstanding Debt

Loan/Credit Card, Where Financed

Balance

Monthly Payment

Outstanding Medical Expenses

Description

Balance

Monthly Payment

Explanation of Need

Please list the circumstances that have caused you to apply for this fund in the space below. Please be as detailed as possible.

Please describe the intended use of the funds. Please be as detailed as possible.

Please describe any other financial resources you have tried to access regarding the situation. These could include: worker's compensation, short-term or long-term disability, property or medical insurance, state or federal agencies, other nonprofit agencies, or any other entity providing assistance. Attach supporting documentation, if applicable and available

Supporting Documentation

Max. file size: 300 MB.

Signature*

By checking this box, I certify that the information given above is true and complete to the best of my knowledge. I have read and understand the policies and procedures of the Hughes Family Assistance Fund. I understand that all decisions made by the Fund Review Committee are final and made in strict confidentiality.

Incomplete applications will not be processed. Please return explanation of need, W9, paystub, and supporting documentation by:

MAIL: Liberty Hospital Foundation PO Box 1002 Liberty, MO 64069

INTER-OFFICE: Liberty Hospital Foundation Medical Plaza East, Suite G20

FAX: (816) 415-5107

E-MAIL: foundation@libertyhospital.org