Download proof needed for financial analysis worksheet

*ITEMS REQUIRED FOR FINANCIAL ASSISTANCE*
Proof of all income in household for the month of date of service:
Paycheck stubs: for the entire month (4 weeks) must have an entire month of proof.
Income Tax Return: for self-employment showing business name and ID
Child Support
Welfare: SNAP
VA Benefits
SSI Benefits
Pension Income
Rental Income
Student Loans (what you receive each quarter)
Bank Statements: including checking account, savings account, money markets, CDs,
mutual funds, etc.
Dividend and Interest Income
*Any and all other income received during the month of service*
Proof of all expenses in household for the month:
Mortgage or Rental Statement
Utility bills (electric, gas, water)
Telephone/Cell Phone bills
Vehicle payment(s) (car, boat and motorcycle)
Any insurance payments (auto, home and life)
Credit card payment receipts
Loan payments
Medical/Dental bill payments
Property Tax payments
Food expenses
Gasoline
Any other payments not noted in this listing
*In some circumstances, you will need hand written statements/letters from
creditors, banks, employers, family members, etc.
*COPY OF DRIVERS LICENSE*
Please provide all information as soon as possible to:
Frances Sanchez | Financial Counselor | Cedar Park Regional Medical Center
Office: 512-528-7032 Fax: 512-528-7223
Email: [email protected]