# Saint Brigid Regional Medical Center: Financial Assistance Application

## About you
- Full name:
- Mailing address:
- Phone:
- Social Security number:
- Hospital account number:

## Your household
- Number of people in your household (you, your spouse or partner, and anyone you claim as a dependent):
- Names and ages of household members:

## Income
- Employer:
- Gross pay per pay period:
- How often you are paid:
- Yearly household income before taxes:
- Other income (child support, benefits, other jobs):

## Request
- Balance you are asking for help with:
- Dates of service:

Signature: ______________________   Date: ____________