Jordan Reyes
18 Quarry Lane, Apt 3
Lantern Hollow
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 for 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, that is $1,640.00 x 26 pay periods = $42,640.00 a year. I have no other income: no child support, no benefits, and no other job. For a household of three, your policy's free care limit is $53,300, so I believe I qualify for free care.

Enclosed are my completed application and my two most recent pay stubs (pay dates September 11 and September 25, 2026).

Please pause all collection activity on my account while you review this 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."

Please send your written decision to the address above. If you need anything else from me, you can call me at 555-0142.

Thank you,

Jordan Reyes

Enclosures: Financial assistance application; pay stubs dated 09/11/2026 and 09/25/2026