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PATIENT NAME
PATIENT NUMBER(S)
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FINANCIAL STATEMENT
2901 Squalicum Parkway -
South Campus
Bellingham, WA 98225
(360) 715-6500 or 384-1005 |
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NAME |
MARITAL STATUS
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SOCIAL SECURITY #
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STREET ADDRESS, CITY, ZIP |
HOW LONG AT THIS ADDRESS
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HOME PHONE
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EMPLOYER'S NAME AND ADDRESS
(IF UNEMPLOYED - HOW LONG)
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BUSINESS PHONE
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POSITION/TITLE |
MONTHLY INCOME - GROSS |
MONTHLY INCOME - NET
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LENGTH OF CURRENT EMPLOYMENT
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NAME |
SOCIAL SECURITY #
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EMPLOYER'S NAME AND ADDRESS
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BUSINESS PHONE
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POSITION/TITLE |
MONTHLY INCOME - GROSS |
MONTHLY INCOME - NET |
LENGTH OF CURRENT EMPLOYMENT
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NAME & YEAR OF BIRTH OF ALL PERSONS IN
HOUSEHOLD (USE LINES PROVIDED BELOW) |
TOTAL # OF PERSONS IN HOUSEHOLD |
DO ANY OTHER PERSONS CONTRIBUTE FINANCIALLY TO
THE FAMILY?
qYES
q
NO IF YES, AMOUNT $
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MISCELLANEOUS INCOME PER
MONTH |
| DIVIDENDS, INTEREST |
$ |
CHILD
SUPPORT/ALIMONY
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$ |
| PUBLIC ASSISTANCE/FOOD STAMPS |
$ |
PENSIONS |
$ |
| SOCIAL SECURITY |
$ |
INVESTMENT/RENTAL INCOME |
$ |
| UNEMPLOYMENT COMPENSATION |
$ |
GRANTS |
$ |
| WORKMEN'S COMPENSATION |
$ |
IRA |
$ |
| SAVINGS
$
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CHECKING $ |
OTHER |
$ |
| ASSETS (OWN) |
VALUE |
LIABILITIES (OWING) |
TO WHOM |
MONTHLY PAYMENT |
BALANCE |
| HOME |
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MORTGAGE/RENT |
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| PROPERTY ACRE(S) LOT(S) |
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REAL ESTATE PROPERTIES |
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AUTO
MAKE MODEL
YEAR |
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BANK LOAN |
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| AUTO LOAN |
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| CREDIT CARDS: |
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| BOAT PLEASURE / COMMERCIAL |
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ACCT#: |
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| LIVESTOCK DESCRIBE: |
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ACCT#: |
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OTHER MONTHLY PAYMENTS (LIST) |
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TRAILER
/ MOTORHOME
MAKE
MODEL YEAR |
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| OTHER |
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MONTHLY MEDICAL PAYMENTS |
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FOOD |
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UTILITIES |
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TOTALS
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INCOMPLETE
OR FRAUDULENT
APPLICATIONS WILL BE DENIED |
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 ST. JOSEPH HOSPITAL OR ITS AGENTS.
SIGNATURE
DATE
RELATIONSHIP IF OTHER THAN PATIENT
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