Charity Care Policy 600-025 - ATTACHMENT A Page 5 of 5
Steele Memorial Medical Center
203 S. Daisy St.
Salmon, ID 83467
Phone: (208) 756-5608
FINANCIAL STATEMENT
1. Head of Household: ______Spouse’s Name: ______
Address: ______
Home Phone: ______Work Phone: ______
2. Occupation (SELF): ______Social Security #: ______
Employer (SELF): ______
Employer Address: ______
Occupation (SPOUSE): ______Social Security #: ______
Employer (SPOUSE): ______
Employer Address: ______
3. Number of members residing in household (FIRST AND LAST NAMES):
Name Relationship Age
______
______
______
______
______
______
______
______
4. Have you ever filed for bankruptcy? YES ______NO ______
5. Do you have any judgements, suits, or litigation pending? YES ______NO ______
6. Income - List all income for household: Monthly Yearly
Wages (Gross – before taxes): ______
Farm or Self-employment: ______
Public Assistance: ______
Social Security/or SSI: ______
Unemployment Compensation: ______
Worker’s Compensation: ______
Strike Benefits: ______
Alimony: ______
Child Support: ______
Military Family Allotments: ______
Pensions/Retirement: ______
Dividends, Interest, Rent, ETC. ______
Sale of Property: ______
Education Grants/ Loans: ______
Inheritance: ______
Royalties: ______
Native American Income: ______
Income Tax Refund ___FED ___STATE ______
Settlement Income: ______
7. Home (Primary Dwelling): Other Property:
Purchase Price: $______Description: ______
Improvements: $______Description: ______
Estimated Value: $______Estimated Value: $______
Financed Through: ______Financed Through: ______
Can you borrow against the equity of either property? YES ______NO ______
If NO, please explain: ______
______
8. Automobiles RV’s, Boats, Motorcycles, ETC
Year/Make Model Value Year/Make Model Value
______$______$______
______$______$______
______$______$______
______$______$______
9. Assets (I own) Account Number Institution Balance/Value
Cash on Hand: ______$______
Checking: ______$______
Savings: ______$______
Auto/RV: ______$______
Home: ______$______
Stocks/Mutual Funds: ______$______
Life Insurance/IRA: ______$______
Bonds/CD’s: ______$______
Mineral Rights: ______$______
Other: ______$______
TOTAL ASSETS: $______
10. Monthly Expenses
Rent: $______Gasoline: $______Food: $______
Insurance(s): $______Electric: $______Childcare: $______
Heating Fuel: $______Child Support: $______Phone: $______
Pharmacy: $______Water: $______Alimony: $______
Cable TV: $______
TOTAL EXPENSES: $______
11. Liabilities (I owe) List Names Current Balance Payment
Bank/Credit Union: ______$______$______
______$______$______
______$______$______
Mortgage Loan: ______$______$______
______$______$______
______$______$______
Auto/RV Loan: ______$______$______
______$______$______
Credit cards/Revolving Acct.: ______$______$______
______$______$______
______$______$______
Medical/Hospital Bills: ______$______$______
______$______$______
______$______$______
Medical/Hospital Bills: ______$______$______
(including dentists)
______$______$______
______$______$______
Collection Agency Accounts: ______$______$______
______$______$______
______$______$______
School Loans: ______$______$______
Other: ______$______$______
Total Liabilities: $______
Total Monthly Payments: $______
11. Additional circumstances or reasons for requesting charity from the hospital or clinic.
______
______
______
______
______
______
______
______
______
______
______
______
______
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Signature: ______Date: ______
Signature (Spouse): ______Date: ______