Financial Assistance Request Application

Acceptable Documentation for Hardship Application

Supporting Documentation:
***In order to process your application, you will need to upload supporting documentation at the bottom of the online application. Please see the list below for appropriate types of documentation.

Documented Proof of Financial Hardship can include But is Not Limited to:

  • W-2 withholding statements
  • Paycheck stubs
  • Income tax return
  • Forms from Medicaid or other State-funded medical assistance
  • Forms from employers or welfare agencies
  • Forms from employers or welfare agencies
  • Proof of unemployment
  • Proof of personal bankruptcy settlement
  • Other documentation that shows you would be unable to pay medical bill and still be able to pay for other basic or necessary expenses

* We will contact you using the information you provide in the form above. Thank you.