# Saint Brigid Regional Medical Center: Financial Assistance Application

## About you
- Full name: Jordan Reyes
- Mailing address: 18 Quarry Lane, Apt 3, Lantern Hollow
- Phone: 555-0142
- Social Security number: XXX-XX-4325 (write the full number by hand on the printed form)
- Hospital account number: 4471-20983

## Your household
- Number of people in your household (you, your spouse or partner, and anyone you claim as a dependent): 3
- Names and ages of household members: Jordan Reyes (me, age: ____); Mia, age 9 (my child); Leo, age 6 (my child)

## Income
- Employer: Harborline Grocery Co-op (Employee ID 20417)
- Gross pay per pay period: $1,640.00
- How often you are paid: Every two weeks (26 pay periods a year)
- Yearly household income before taxes: $42,640.00 ($1,640.00 x 26 pay periods)
- Other income (child support, benefits, other jobs): None. No child support, no benefits, no other job.

## Request
- Balance you are asking for help with: $4,812.50
- Dates of service: 08/14/2026

Signature: ______________________   Date: ____________