Manchester Lions Club

373 S. Willow St #132 MANCHESTER LIONS CLUB Manchester, NH 03103 APPLICATION FOR EYECARE AID

IF YOU DO NOT SPEAK ENGLISH YOU MUST PROVIDE AN INTERPRETER!

All questions MUST be answered if this application is to be considered. Information revealed herein will be kept strictly confidential and will be used solely for the evaluation of you request for financial assistance. NO professional treatment will be paid for by the Lions Club unless expressly authorized in writing by our President or designated member. THIS IS A ONE TIME ASSISTANCE PROGRAM.

1. APPLICANT______First Name Middle Initial Last Name 1A. SOCIAL SECURITY NUMBER ______--______--______Date of Birth______2. REFERRED BY: ______TODAY’S DATE______3. CURRENT ADDRESS______Street City Zip Code Number of years there 3A. PREVIOUS ADDRESS______Street City Zip Code Number of years there 4. INDICATE WHETHER APPLICANT IS ALREADY ELIGIBLE FOR EYE CARE AID FROM THE FOLLOWING SOURCES: The Lions are able to help only those who have no one else to turn to for eye-care aid. If you’re not sure of eligibility from the following, please call them and ask. If they indicate you’re not eligible, please indicate the reason below. Yes/No ______SCHOOL CHILDREN from kindergarten to graduate of 12 years---Healthy Kids Program or other source. ______INCOME ASSISTANCE from anywhere ______PERMANENTLY DISABLED individuals* ______SENIOR CITIZENS age 65 or older* or having Medicare coverage/please list card number______TANF recipients* ______MEDICAID COVERAGE* please list card number______Spend down amount ______UNITED STATES VETERAN *Eye-care is provided by Medicaid (if these individuals are financially needy) thru the NH Division of Human Services REASON:______

5. PHONE NUMBER WHERE YOU CAN BE REACHED______TIME TO CALL______

6. EMPLOYER______OCCUPATION______

DATE HIRED______NET INCOME______/MONTHLY DATE LEFT______

6A. PREVIOUS EMPLOYER______OCCUPATION______

DATE HIRED______NET INCOME______/MONTHLY DATE LEFT______

7. OTHER INCOME: DATE STARTED DATE ENDED AMOUNT / MONTHLY Pension ______Investments ______Social Security ______Workmen’s Compensation ______Unemployment Compensation ______NH Welfare ______TANF (Temp. Aid for Needy Families) ______Other ______Total ______

8. PLEASE COMPLETE THE FOLLOWING FOR ALL INDIVIDUALS LIVING WITH APPLICANT: Name Relationship Age Monthly Income ______9. Child Support:______(monthly) Alimony: ______(monthly) VA Disability: ______(monthly)

Total value of : Checking and Savings accounts $______Investments $______

Car 1 ______Amount of Loan Payment ______Year Make Monthly Car 2 ______Amount of Loan Payment ______Year Make Monthly Real estate owned: Description______Current value $______

10. HOUSEHOLD EXPENSES THAT YOU PAY: Apartment rent/Mortgage payment ______monthly AND/OR Amount paid by Section 8 pays______

Heat & Electric ______monthly Amount of fuel assistance received______

Food allowance received ______monthly Recurring medical expenses ______monthly

List other expenses: ______

10A. ARE YOU RECEIVING HEAT, HOUSING OR FOOD ASSISTANCE OF ANY KIND? ___ MONTHLY AMOUNT______

11. HAVE YOU PREVIOUSLY APPLIED TO A LIONS CLUB FOR EYE-CARE AID? ______YEAR? ______

12. WHAT EYE PROBLEMS ARE YOU EXPERIENCING? ______

13. YES or NO, do you need: LENSES______FRAMES______EXAM______

14. Date of last eye exam:______Doctors Name:______Address:______

15. ADDITIONAL INFORMATION (IF NECESSARY) THAT WOULD HELP DEMONSTRATE FINANCIAL NEED: ______

16. AMOUNT APPLICANT CAN PAY TOWARDS EXPENSE: $______

17. I, the APPLICANT, certify that this application is accurate and complete. I hereby authorize any individual or organization to release to the MANCHESTER LIONS CLUBS OF NH any information necessary to confirm statements made in this application. In consideration of any aid, which may be granted, I agree to hold the MANCHESTER LIONS CLUBS OF NH harmless from any injury resulting from treatment paid by them. I ALSO UNDERSTAND THAT THERE ARE NO EXPRESSED OR IMPLIED SERVICES OTHER THAN A POSSIBLY EXAM AND GLASSES.

Applicant’s Signature______

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APPROVED: Y_____ N_____ Reason for denial______

CLUB CONTACT ______NAME PHONE NO. DATE ______C: DOCUMENTS/MNCH/EYE CARE APPLICATION, UPDATED 9/2/13