Form F-44614a - Aids Drug Assistance Program And Insurance Assistance Application - 2017 Page 2
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3F-44614A (Rev. 02/2017)
Page 2 of 3
Physician Information
Pharmacy Information
Physician Name
Pharmacy Name
Clinic Name
Contact Person
Street Address
Street Address
City
State
Zip Code
City
State
Zip Code
Telephone Number
Telephone Number
Fax Number
SECTION II. FINANCIAL INFORMATION
Use the space below to list all sources of income and the amount of monthly gross income from each source. You must attach proof of
the income listed below. Attach a copy of the most recent benefits, paycheck stub(s), copy of your latest tax return (if self-
employed or you have non-wage income), or a copy of your award letter whichever most accurately provides proof of your
current income.
Source (Monthly)
Self
Spouse
Total
Gross wages and salary
$ 0.00
Social Security Disability Income (SSDI)
$ 0.00
Social Security Supplemental Income (SSI)
$ 0.00
Dividends and interest
$ 0.00
Estate/trust income, net rental income, and/or royalties
$ 0.00
Public assistance
$ 0.00
Pensions, annuities, and/or veteran’s pension
$ 0.00
Unemployment and/or worker’s compensation
$ 0.00
$
$
$
$ 0.00
$ 0.00
$ 0.00
TOTAL OF ALL SOURCES
I am supported by:
If you have no income, you must indicate how you are
supported (i.e., relatives, friends).
If married, does your spouse have income?
Yes
No
If yes, please include proof of income.
Family Size
If your family size is more than 1, list your spouse and/or legal dependents. Use additional paper if necessary.
Name of Family Member
Birth Date
Relationship to Applicant
Enrolled in school?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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