Enclosed is the application for the Assistance Program 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section A, where you will enter your full name, current address, phone number, and Social Security Number. Ensure all details are accurate for processing.
3. In Section B, provide information about your spouse or any other adult living at your primary residence. Fill in their full name and Social Security Number if applicable.
4. Proceed to Section C to list dependents. For each dependent, include their name, date of birth, and relationship to you.
5. In Section D, detail your monthly expenses by listing creditors and payments. Indicate if any bills are past due.
6. Section E requires information about your insurance status. Answer whether you have insurance and provide details on deductibles if applicable.
7. For Section F, indicate whether services have already been provided or list anticipated services along with physician names.
8. Finally, review Section G for the disclaimer and sign the application before submitting it via mail or email as instructed.

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