ࡱ> Z\Yg qbjbjXX 4T2\2\ c D4b&f[[[%%%%%%%$'~*&[[[[&&"""["%"[%""@" ʲ}R"%2&0b&"+"+""0+"[["[[[[[&&[[[b&[[[[+[[[[[[[[[ > :   Applicant Name: ______________________________________ Date of Birth: _____________ Parents Names (when applying for a child): _________________________________________ _________________________________________ Address: ____________________________________________ Apt. # ____________ City: ________________________________State______ZIP_________ Daytime Telephone: ( ) ____-________ Cell Number: ( ) ____-_________ Is the Applicant a permanent resident of Wisconsin (circle one)? Yes No How long have you been at your current address? ________________ Insurance: Name & policy numbers of any/all health insurance polices: __________________ ____________________________________________________________________________ Have you checked if your insurance policy covers hearing aids? (Circle one) Yes No If you answered yes above, how much will your insurance cover? __________________________ Have you checked if you qualify for Medicaid? Yes No N/A Marital Status (circle one): Single Married Widowed Separated List Names, Ages, and Relationship of Everyone in Household: _______________ _____________________________________________________________________________ When was the last time your hearing was evaluated? ______________________________ Are you currently working with a hearing professional? (Circle one) Yes No If yes, please provide following: Name________________________________________ Address______________________________________ City______________________State____ZIP________ Telephone ( ) ____-_______ --------------------------------------EMPLOYMENT INFORMATION-------------------------------- Parents or Guardians employment information is necessary when applying for a child or dependent I am currently (circle one): Employed Unemployed Retired Disabled If employed, please complete the following: Present Employer: _______________________________________________________ Employer Address: _______________________________________________________ City, State, ZIP _______________________________________________________ Telephone: ( ) ____-__________ Position: ________________________________ Gross Monthly Income $____________ Net Monthly Income $ ______________ If married, your spouse is currently: Employed Unemployed Retired Disabled If employed, please fill out information pertaining to spouse's employment: Spouse or Name (If applying for child): _________________________________ Present Employer: _______________________________________________________ City, State, ZIP _______________________________________________________ Telephone: ( ) ____-__________ Position: ________________________________ Gross Monthly Income $_______________ Net Monthly Income $ __________________  Gross Income (before taxes/deductions) & Investments Monthly Expenses (monthly average)Monthly Social Security Benefits$Rent/Mortgage (circle one)$Spouses Social Security Benefits$Utilities$Monthly Retirement Pension$Food$Monthly Food Stamp Benefits$Phone$Monthly Child Support $Medicine/Medical$Other Income$Car/Transportation$$Child Care$** RequiredHome Insurance$Assets (savings, checking, CDs, etc.)$List Charge Cards $$$$Other expenses$Investments (IRA, 401-K, etc.)$$$Total Monthly Expenses$ ---------------------------------OTHER ASSISTANCE PROGRAMS--------------------------------- Please check each of the following programs you are currently eligible for or have applied for: ______ Medicaid (Title 19) Please note - this is not the same as Medicare (Title 18) ______ Department of Vocational Rehabilitation (DVR) ______ Badger Care Plus ______ Other Please List ___________________________________________________________ ---------------------------------------------------------------------------------------------------------------------------------------------------------- I understand this application will be reviewed by members of the Lions/Lioness organization in order to determine the applicant's eligibility status. I give my permission to the WLF Hearing Program to release this application to the appropriate members for their review. In addition, I give my permission to have the information provided on this application verified. I certify that all of the information provided is current and accurate to the best of my knowledge. If any information is falsely stated, or if I am working with another assistance program I understand it will disqualify me from the WLF Hearing Aid program. __________________________________________ - or - _________________________________________ Signature of Applicant Signature of Parent, Guardian, or POA ______________ Date Signed  Please return this form to: WLF Hearing Aid Program 3834 County Road A Rosholt, WI 54473 Phone: (877) 463-6953 (toll-free) Fax: (715) 677-4527  WISCONSIN LIONS FOUNDATION, INC. HEARING AID PROGRAM Application for Financial Assistance for Hearing Aid(s) ** REQUIRED FINANCIALS: Please enclose 3 months of your most current Bank/Financial Statements. ALSO, enclose a copy of proof of income such as last year's Federal and State Tax Returns, and/or Social Security or Disability Benefit Statements, Pension Statements, Latest Paycheck with year-to-date earnings. Proof of financials is required for you, your spouse, and other's living in your same household. Financial guidelines are based on TOTAL household income. 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