608 829 5254-2025

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The document is a Financial Statement form used by the University of Wisconsin Medical Foundation and University of Wisconsin Hospital and Clinics to assess eligibility for the Community Care program. It collects detailed information about patients' family members with outstanding balances, guarantor details, income sources, monthly expenses, assets, and liabilities. The form emphasizes confidentiality and requires signatures for verification.

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Versions	Form popularity	Fillable & printable
2014	4.8 Satisfied (116 Votes)

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