Check List For Lsha Financial Assistance Application
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1CHECK LIST FOR LSHA FINANCIAL ASSISTANCE APPLICATION
(Refer to policies and guidelines for further clarification)
Applicant_________________________________________________Date______________________________________
Submitted by_______________________________________Primary Care Location_______________________
Must have two (2) different documents or old mail with name, physical address, and a date that
1. PROOF OF RESIDENCY
is
one (1) year old. Documents should not be older than two (2) years old. (if you can’t
find anything dated a year to two years old, think of ANYWHERE that may have your name and
OVER
address on file that can print out an old statement or bill) Examples: old hospital bill, electric
bill, pharmacy printout, etc.
**
It’s ok if it has an old Columbia County address on
it**
**If renewing, just one (1) current document/mail must be provided.
(2 of the following) Adult- 1 must be Photo ID
Birth Certificate
2. IDENTIFICATION
Florida Drivers License/FL Identification card
(No out of state identification will be accepted)
o
Voter Identification Card
o
Passport
Official document that includes name, address, and social security number (i.e. tax form
o
or social security document)
o
o Alien Registration receipt card (Green Car d, Form I-151 or I-551)
o
Any government issued photo identification
o
Most recent tax return, 1040 (including supporting schedules) and W-2’s for all wage
3. INCOME:
Please bring
ALL
that apply to you!!
earners in household
Pay stubs for previous 8 weeks or Income Verification form-employer
o
Bank Statements (previous 3 months for all accounts) (include all pages)
Medicaid Denial Letter or Medicaid application/case number
o
Unemployment/Workers Comp Statement
o
Child Support/Alimony
o
Social Security Benefits for any family member
o
Pensions/Retirement/Interest/
o
Veterans Benefits
o
Any settlements, court ordered or otherwise
o
Other appropriate supporting documents
o
Self Employment
o
a. Bank statements for all business accounts (3 mos.)
o
b. Previous Year’s Business Tax Return (complete w/attachments/schedules
o
c.
Current Business Financial Statements
Assets
a. Checking and Savings accounts
b. Equity value of real property other than homestead
o
c.
Cash surrender value of life insurance if combined face value of all policies
owned by the family unit exceeds $1500.
d. Additional automobiles, motorized vehicles, motorcycles
e. Recreational vehicles
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Parent category: Life