INCOME INFORMATION. Yes No MONTHLY GROSS INCOME I am self employed. (List nature of self employment) (use net income from business) $ I have a job and receive wages, salary, overtime pay, commissions, fees, tips, bonuses, and/or other compensation: List the businesses and/or companies that pay you: Name of Employer 1) 2) 3) $ $ $ I receive cash contributions of gifts including rent or utility payments, on an ongoing basis from persons not living with me. $ I receive unemployment benefits. $ I receive Veteran’s Administration, GI Xxxx, or National Guard/Military benefits/income. $ I receive periodic social security payments. $ The household receives unearned income from family members age 17 or under (example: Social Security, Trust Fund disbursements, etc.). $ I receive Supplemental Security Income (SSI). $ I receive disability or death benefits other than Social Security. $ I receive Public Assistance Income (examples: TANF, AFDC) $ I am entitled to receive child support payments. I am currently receiving child support payments. If yes, from how many persons do you receive support? I am currently making efforts to collect child support owed to me. List efforts being made to collect child support: $ $ I receive alimony/spousal support payments $ I receive periodic payments from trusts, annuities, inheritance, retirement funds or pensions, insurance policies, or lottery winnings. If yes, list sources: 1) 2) $ $ I receive income from real or personal property. (use net earned income) $ Student financial aid (public or private, not including student loans) Subtract cost of tuition from Aid received $ Asset information YES NO INTEREST RATE CASH VALUE I have a checking account(s). If yes, list bank(s) 1) 2) % % $ $ I have a savings account(s) If yes, list bank(s) 1) 2) % % $ $ I have a revocable trust(s) If yes, list bank(s) 1) % $ I own real estate. If yes, provide description: $ I own stocks, bonds, or Treasury Bills If yes, list sources/bank names 1) 2) 3) % % % $ $ $ I have Certificates of Deposit (CD) or Money Market Account(s). If yes, list sources/bank names 1) 2) 3) % % % $ $ $ I have an XXX/Lump Sum Pension/Xxxxx Account/401K. If yes, list bank(s) 1) 2) % % $ $ I have a whole life insurance policy. If yes, how many policies $ I have cash on hand. $ I have disposed of assets (i.e. gave away money/assets) for less than the fair market value in the past 2 years. If yes, list items and date disposed: 1) 2) $ $ STUDENT STATUS YES NO Does the household consist of all persons wh...
INCOME INFORMATION. 8. Enter the total family size from your current federal tax return This includes you, your spouse if filing jointly, and all dependents listed on your Federal 1040, including qualifying relatives.
INCOME INFORMATION. Yes No MONTHLY GROSS INCOME I am self employed. (List nature of self employment) (use net income from business) $ I have a job and receive wages, salary, overtime pay, commissions, fees, tips, bonuses, and/or other compensation: List the businesses and/or companies that pay you: Name of Employer 1) $
INCOME INFORMATION. Monthly Income Sources Applicant Co-Applicant Combined Monthly Income Employment $ $ $ Social Security $ $ $ Disability $ $ $ Unemployment $ $ $ Spousal/Child Support $ $ $ Rental Property $ $ $ Investment Income $ $ $ Other: $ $ $ $ $ $ $ $ $ Total Combined Monthly Income $ UNEMPLOYMENT: If you do not have monthly income, please explain how you take care of your monthly expenses.
INCOME INFORMATION. Do you receive any of the following? Indicate if received money from: Amount • Supplemental Security Income (SSI) Benefits Yes No • Social Security Disability Benefits Yes No • Social Security Dependent Benefits Yes No • Social Security Survivor’s Benefits Yes No • Social Security Retirement Benefits Yes No • NYS Disability Yes No How do you see the trust money being spent? Referral Source: Name email:
INCOME INFORMATION. 8. Enter the total number of claimed exemptions from your current federal tax return (Line 6d of the 1040 or 1040A, or line 5 of the 1040EZ) .........................................................
INCOME INFORMATION. Please provide proof of total household income (i.e. Check Stubs, Bank/Financial Statements, SSI/Disability Letters, etc.)
INCOME INFORMATION. Everyone must answer all questions in this section. □ □ Did you receive any unemployment benefits during the year? □ □ Did you receive any disability income during the year? □ □ Did you receive any Social Security benefits during the year? □ □ Did you receive any income in 2017 not reported on a tax form and not written in the organizer you are providing to me? If so, how much? $ and from what source? □ □ Did any of your life insurance policies mature, or did you surrender any policies? □ □ Did you receive any awards, prizes, hobby income, gambling or lottery winnings? □ □ Do you own any savings bonds that matured in 2017? (Issued in 1987) □ □ Did you engage in any bartering transactions in 2017? □ □ Do you know why the Secret Service was originally established to do? □ □ Did you have any foreign income and/or pay any foreign taxes during the year, directly or indirectly, such as from investment accounts, partnerships or a foreign employer? □ □ Did you receive any income in 2017 from property sold prior to 2017? (ie: installment sale proceeds) □ □ Did you receive any property tax refunds or credits in 2017? If so, what was the amount? $
INCOME INFORMATION. Marital Status: Yourself Spouse Job title/occupation: Employer: How long there: Payroll address: City, ST Zip Payroll office phone #: Date next paycheck expected CHILDREN & STEP-CHILDREN Name Age Relationship Does child live with you? Child support $ paid/received EXPECTED CHANGES IN INCOME: Describe when & why: INCOME & EXPENSES Please note that under current bankruptcy laws, a debtor must provide the previous seven (7) months of household income in order to evaluate a case for means testing purposes. Therefore, please provide copies of your paystubs for the past seven (7) months. If you are self employed, please provide documentation of your income from the past seven (7) months. Additionally, if you have other sources of income, please provide documentation of that income as well.
INCOME INFORMATION. Family members in patient's household Total Monthly Income (From Worksheet Part B, Line 1) SECTION Ill: ATP LIABILITY In consideration for being charged for health care services rendered by the County of Los Angeles (County) to the patient in accordance with the County's Ability-to-Pay Plan (ATP), I/we (patient or responsible relative) --- -------'promisetopay the Countyforservicesreceivedfromthe County'shealthcare facilities, from through ,thATP Liability Amount of: dollars ($ per admission for all inpatient services provided to the patient covered by this Agreement from admission until discharge from the County's Health care facility; AND - -dollars ($· -- f eachmonthduringwhichoutpatientservicesarereceivedby the patient covered by this Agreement for all outpatient visits provided during that month. SECTION IV: ATPCERTIFICATION Such ATP Liability Amount has been determined under the ATP and is based upon information which I/we provide in this Agreement. I/we understand that I/we may be asked later for proof of some or all of the information used for this Agreement. I understand that I am expected to save documents I might have that would help prove that what I said today is true, (for example, copies of pay stubs, income tax returns, bank statements, receipts), for 6 months from the date of the application. If I am asked for these documents in the next 6 months, I will have 20 days to mall or bring the information to the facility or to give some other acceptable verification. If I am asked for this proof and don't provide it, I may be held responsible for the full charges for my medical care. It is understood and agreed that the above ATP Liability Amount for such inpatient services or for such outpatient services shall not be subsequently adjusted for any reason except as provided under the ATP. I/we understand and agree that this Agreement shall be governed by the terms and conditions set forth in the ATP, which has been made available to me/us for review and which is incorporated herein by reference, and that I/we shall fully cooperate with the County in accordance with the ATP. Pursuant to Section 360.5 of the California Code of Civil Procedure, I/we agree that all statutes of limitation upon the debt for the health care services which are covered by the Agreement are hereby waived. I/we certify that, during the next year, if the patient gets or loses insurance, or if his or her family size or income changes, I/we promise to immediately report that f...
