FA Application – Carlinville Area Hospital & Clinics

Online Application

"*" indicates required fields

Welcome to your Carlinville Area Hospital & Clinics online financial assistance application!

In order to process your application, we need supporting documents to verify your financial situation. Required documents include any of the following that apply to your household:

Untitled
Pay Stubs (last two months)
Proof of Income for All Income Sources (last two months)
Bank Statements for Checking and Savings Accounts (last two months)
Previous Year’s Tax Return

After reviewing your submitted application, we may reach out to assist you with additional programs and insurance options available to you.

Please get an electronic copy or pictures of your documents ready before starting your application. If you submit an incomplete application, we will reach out to you via mail for any additional information or documentation needed to process your application.

Applicant Name*

First Middle Last

Social Security Number

Date of Birth*

Address*

Street Address City State ZIP Code

Phone Number*

What is the APPLICANT’S gross monthly income from all sources? If none, enter 0.*

Including yourself, what is the total number of people living in your household?*

Additional Household Member 1 – Name*

First Last

Additional Household Member 1 – Date of Birth*

Additional Household Member 1 – Relationship to Applicant*

What is Additional Family Member 1's total gross monthly income from all sources? If none, enter 0.*

Additional Household Member 2 – Name*

First Last

Additional Household Member 2 – Date of Birth*

Additional Household Member 2 – Relationship to Applicant*

What is Additional Family Member 2's total gross monthly income from all sources? If none, enter 0.

Additional Household Member 3 – Name*

First Last

Additional Household Member 3 – Date of Birth*

Additional Household Member 3 – Relationship to Applicant*

What is Additional Family Member 3's total gross monthly income from all sources? If none, enter 0.

Additional Household Member 4 – Name*

First Last

Additional Household Member 4 – Date of Birth*

Additional Household Member 4 – Relationship to Applicant*

What is Additional Family Member 4's total gross monthly income from all sources? If none, enter 0.

Additional Household Member 5 – Name*

First Last

Additional Household Member 5 – Date of Birth*

Additional Household Member 5 – Relationship to Applicant*

What is Additional Family Member 5's total gross monthly income from all sources? If none, enter 0.*

Additional Household Member 6 – Name*

First Last

Additional Household Member 6 – Date of Birth*

Additional Household Member 6 – Relationship to Applicant*

What is Additional Family Member 6's total gross monthly income from all sources? If none, enter 0.

Additional Household Member 7 – Name*

First Last

Additional Household Member 7 – Date of Birth*

Additional Household Member 7 – Relationship to Applicant*

What is Additional Family Member 7's total gross monthly income from all sources? If none, enter 0.

If your household's total income is zero, please provide an explanation for how you are being supported.

Uploading Documents

This section is for attaching the documents we need to fully process your application and verify the information you provided. Please include copies of all of the following that apply to your household.

Pay Stubs

Please upload paystubs for all income earners for the past 2 months, if applicable.

Drop files here or