Jordan Reyes
18 Quarry Lane, Apt 3
Lantern Hollow
Phone: 555-0142

Financial Assistance Office
Saint Brigid Regional Medical Center
400 Harbor Road
Lantern Hollow

Re: Financial assistance application, account 4471-20983

To the Financial Assistance Office:

I am applying for financial assistance with my balance of $4,812.50 for emergency care I received on August 14, 2026 (emergency department visit, CT scan, and laboratory panel). My first statement is dated August 28, 2026.

My household is three people: me and my two children, Mia (9) and Leo (6). I work at Harborline Grocery Co-op and am paid $1,640.00 gross every two weeks. Using your policy's method, my yearly household income is $1,640.00 x 26 = $42,640.00. We have no other income: no child support, no benefits, and no other job.

Your policy lists a free care limit of $53,300 for a household of three. Because $42,640.00 is at or below that limit, I am asking that the full balance be covered as free care.

I also ask that you pause all collection activity on this account while you review my application. Your Financial Assistance Policy states: "If you apply, we pause all collection activity on the account, including referral to a collection agency, until we send you a written decision."

Enclosed are my completed application form and my two most recent pay stubs (pay dates 09/11/2026 and 09/25/2026). Please contact me at 555-0142 if you need anything else.

Thank you,

______________________
Jordan Reyes
Date: ____________