Financial Assistance Application

This form is to be completed by all individuals seeking financial assistance from Heartspring. All information is regarded as confidential and viewed only by those involved in the approval of assistance agreements. Assistance is provided only after all other applicable sources of funding have been used. Financial assistance decisions are made without regard to race, sex, ethnic origin or religious affiliation. Funds available for assistance are limited. Heartspring reserves the right to alter or suspend granted assistance agreements should the fiscal need arise. Financial assistance is not guaranteed and must be renewed annually.

Heartspring relies on all sources of income to fund its programs, including timely payments by clients. Client charges are due at the time of service. Failure to make agreed upon payments in a timely manner will result in termination of financial assistance and subsequent charges are to be billed at the full rates. In addition, Heartspring reserves the right to terminate services for non-payment of agreed upon rate.

To be considered for eligibility for Heartspring Financial Assistance please complete the form in its entirety with the following within 15 days:

Two (2) months of previous pay stubs
Copies of child support, unemployment, and social security/SSI stubs

"*" indicates required fields

Child's Information

Name*

First Middle Last

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Country

Parent/Guardian 1 Information

Name*

First Middle Last

Address Same as Child*

Yes

Address*

Address Address Line 2 City State ZIP Country

Home Phone

Cell Phone

Work Phone

Employer Name*

Parent/Guardian 2 Information

Add Parent/Guardian 2

Yes

Name*

First Middle Last

Address Same as Child or Parent/Guardian 1*

Yes, same as Child

Yes, same as Parent/Guardian 1

Address*

Address Address Line 2 City State ZIP Country

Home Phone

Cell Phone

Work Phone

Employer Name*

Family Size/Income

List ALL family members living in the home, including the child being served. Mark N/A if family member has no income. Include all income sources.

List*

Member Name

Relationship

Source

Monthly Gross Income

Number of Family Members*

Family Gross Income*

Frequency

Attachments

To be considered for eligibility for Heartspring Financial Assistance, please submit the following documents within 15 days.
• 2 months of previous pay, unemployment, or social security/SSI stubs
• Or current tax returns

File

Max. file size: 50 MB.

File

Max. file size: 50 MB.

File

Max. file size: 50 MB.

File

Max. file size: 50 MB.

File

Max. file size: 50 MB.

File

Max. file size: 50 MB.

File

Max. file size: 50 MB.

File

Max. file size: 50 MB.

File

Max. file size: 50 MB.

File

Max. file size: 50 MB.

If you are unable to upload these documents, please check the box below.

I am unable to upload these attachments at this time. I understand that my application will not be processed until I mail, fax, email, or hand deliver the necessary documents listed above within 15 days of my application submission.

Additional Information

Use the field below to provide us with any information we may have missed.

Signature*

I certify that the information provided, to the best of my knowledge, is correct. I agree to notify Heartspring of any changes in my financial status.