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Methodist Hospital of ChicagoCharity Hospitalization Program |
| Patient Name:______________________________ | Admission(s) # ______________________________ |
| GUARANTOR INFORMATION | |
| Name: ______________________________ ____ | Relationship To Patient: ______________________________ |
| Address: ________________________________ | Employer: _________________________________________ |
| City: ____________________________________ | Employer's Phone: __________________________________ |
| State & Zip Code: _________________________ | Spouse's Name: ____________________________________ |
| Home Phone: _____________________________ | Spouse's Date of Birth: _______________________________ |
| Social Security #: __________________________ | Social Security #: ___________________________________ |
| Date of Birth: _____________________________ | Spouse's Employer: _________________________________ |
| Employer's Phone: __________________________________ | |
| Please indicate the number of dependents you | |
| Claimed on last year's IRS Income Tax Return: ________________ | |
| INCOME AND ASSETS | |
| Guarantor's Monthly Gross Income: $______________ | |
| Spouse's Monthly Gross Income $______________ | |
| Other Monthly Income* $______________ | |
| Total Monthly Income: $______________ x 12 - $______________ = Total Annual Gross Income | |
| Bank Name:** ___________________ | Checking Account Balance: $______________ |
| Savings Account Balance: $______________ | |
| Retirement/ 401K/ CD, etc. ______________ | |
| Source of Other Income: ________________ | |
| * Include child support, alimony, disability, welfare, food stamps, and unemployment compensation | |
| ** Provide copy of bank statement | |
| List of all major assets and their value (Automobile(s), Property, etc; Do not list primary residence) | |
| Item Value Estimated | |
| __________________________________________ | $___________________ |
| __________________________________________ | $___________________ |
| __________________________________________ | $___________________ |
| __________________________________________ | $___________________ |
PLEASE PROVIDE A COPY OF YOUR DRIVER'S LICENSE (OR STATE ID) AND SOCIAL SECURITY CARD. ALSO INCLUDE A COPY OF LAST YEAR'S W-2 FORMS, INCOME TAX STATEMENT OR LAST 2 PAY STUBS. |
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| The information disclosed above is true and represents a total disclosure of all obligations. I authorize Methodist Hospital of Chicago to obtain credit reports, or other financial confirmation. I will promptly notify Methodist hospital of Chicago if my financial position significantly changes. | |
| __________________________________ | __________________________________ |
| Patient Signature | Date |
| __________________________________ | __________________________________ |
| Guarantor Signature (if applicable) | Date |