Financial Assistance - Ritual Medical

Ritual Medical Financial Hardship Application

First Name

Last Name

Date of Birth

Phone Number

Street Address

State

ZIP Code

Please list your current employer(s) and job title(s).

What is your total monthly salary?

Please list all household members and their ages.

What is the total monthly income of your household?

What is the average of your total monthly expenses for your household?

What is your health insurance status?

Insured Uninsured

Please estimate your current medical expenses (year to date).

In your own words, what is the reason for your request for financial assistance?

I certify that the information provided in this application is true and accurate to the best of my knowledge. I understand that providing false information or omitting relevant information may result in the denial of financial assistance and may be grounds for termination of any assistance granted.

Applicant Signature

Date

Please upload your proof of income. (See "Proof of Income" instructions below).

Proof of Income

Please provide at least one of the following documents as proof of income:

Most recent W-2, 1099, or IRS tax return (1040EZ, etc.)
Pay stubs for the past 90 days
If tax or pay stub information is not available, provide a signed letter from your employer stating cash earnings.
For business owners/self-employed, provide a self-distribution statement.
Unemployment or disability check stubs for 90 days and/or letter detailing unemployment benefits from your state unemployment office.
Military leave and earnings statement.
Proof of all other income (SSI, SSDI, pensions, etc.)
Application forms and/or statements for government and/or other sponsored assistance

Note: Bank statements do not qualify as proof of income.