<p> CONNECTICUT CHILDREN’S FINANCIAL ASSISTANCE APPLICATION</p><p>PATIENT NAME: </p><p>PATIENT #: </p><p>MEDICAL RECORD #: </p><p>I. RESPONSIBLE PARTY </p><p>LAST NAME FIRST NAME MI MARITAL STATUS SOCIAL SECURITY #</p><p>STREET ADDRESS</p><p>HOW LONG AT THIS CITY STATE ZIP ADDRESS? HOME PHONE</p><p>EMPLOYER'S NAME AND ADDRESS BUSINESS PHONE LENGTH OF EMPLOYMENT</p><p>POSITION/TITLE MONTHLY INCOME PAY PERIOD $</p><p>II. SPOUSE’S INCOME</p><p>LAST NAME FIRST NAME MI MARITAL STATUS SOCIAL SECURITY #</p><p>STREET ADDRESS</p><p>CITY STATE ZIP HOW LONG AT THIS ADDRESS? HOME PHONE</p><p>EMPLOYER'S NAME AND ADDRESS BUSINESS PHONE LENGTH OF EMPLOYMENT</p><p>POSITION/TITLE MONTHLY INCOME PAY PERIOD $</p><p>III. HOUSEHOLD INFORMATION (ALL PERSONS IN HOUSEHOLD)</p><p>NAME DOB RELATIONSHIP</p><p>TOTAL PERSONS IN HOUSEHOLD:</p><p>1 IV. MISCELLANEOUS INCOME PER MONTH</p><p>DIVIDENDS, INTEREST $ PENSIONS $ PUBLIC ASSISTANCE/FOO INVESTMENT/REN D STAMPS $ TAL INCOME $ SOCIAL SECURITY $ GRANTS $ UNEMPLOYMENT/ WORKER’S COMPENSATION $ Other $ CHILD SUPPORT/ALIMON Y $ TOTAL MONTHLY MISCELLANEOUS INCOME: $</p><p>VI. MONTHLY INCOME </p><p>RESPONSIBLE PARTY's MONTHLY INCOME $ SPOUSE's MONTHLY INCOME (If Applicable) + $0 TOTAL MONTHLY MISCELLANEOUS INCOME + $ TOTAL MONTHLY MISCELLANEOUS EXPENSES - $ TOTAL MONTHLY NET INCOME = $</p><p>INCOMPLETE OR FRAUDULENT APPLICATIONS WILL BE DENIED</p><p>IN COMPLETING THIS FINANCIAL STATEMENT, I HEREBY AFFIRM THAT THE ABOVE STATEMENTS ARE CORRECT AND COMPLETE, AND I GIVE MY CONSENT TO FURTHER VERIFICATION BY {HOSPITAL NAME} OR ITS AGENTS. </p><p>SIGNATURE/ DATE: ______/______</p><p>RELATIONSHIP IF OTHER THAN PATIENT: ______</p><p>VERBAL CONSENT: ______</p><p>APPROVED 45%_____ 100%_____</p><p>DENIED ______</p><p>Please be advised that you may be asked to provide verification of income (tax return or pay stubs) upon review of your application. You will be contacted by a financial counselor via phone if this information is required. Otherwise, you will receive a determination phone call and letter in the mail indicating the outcome of the application. </p><p>2</p>