Dr. Ann Stadelmaier Hearing Aid Fund Form

To submit this form manually, click download and follow the instructions.

Personal Information:

Name *

Date *

Date of Birth *

Street Address *

City *

State *

Zip *

Phone # *

Email *

Number Living in Household *

Number of Adults *

Children's Ages

Employer *

Job Title

How did you hear about the Dr. Ann Stadelmaier Fund? *

Medical Information:

Health Insurance Provider *

Medicaid *
YesNo

Medicare *
YesNo

Emergency Contact Name *

Relationship *

Phone # *

Name of Audiologist/Physician *

City *

Phone # *

I hereby authorize the above named Audiologist/Physician to release any information necessary to process this application.

Household Income and Asset Declaration:

Please attach a copy of pages 1 and 2 of your most recent IRS Tax Return and supporting documentation in a zip file for all items marked YES (√) with this application.

Social Security / Social Security Disability including direct deposit (Gross monthly deposit) *
YesNo

Monthly Amount

Amount deducted for Medicare Part B

Who Receives?

Supplemental Security Income (SSI) *
YesNo

Monthly Amount

Who Receives?

Food Stamps/Other Nutritional Support Services *
YesNo

Monthly Amount

Who Receives?

Pension/Retirement (All types) *
YesNo

Monthly Amount

Source of Pension

Who Receives?

Veteran’s Benefits *
YesNo

Monthly Amount

Who Receives?

Disability private or NYS *
YesNo

Weekly Amount

Source

Who Receives?

Total value of all savings, checking, CD’s, money market accounts, etc. (Send statement Copy)

Checking *

Savings *

CDs *

Money Market *

Other *

Source(s) *

Who Receives? *

Interest from savings, checking, CD’s, money market accounts, etc.

Interest from savings, checking, CD’s, money market accounts, etc.
YesNo

Yearly Amount

Source(s)

Who Receives?

Total value of all stocks, bonds, etc.

Total value of all stocks, bonds, etc.
Stocks Amount *

Bonds Amount *

Source(s)

Who Receives?

Dividends from stocks, bonds, securities, etc. *
YesNo

Yearly Amount

Source(s)

Who Receives?

Does anyone in the household work? If yes, submit wage stubs for the past four (4) weeks *
YesNo

Weekly Amount (before deductions)

Employer

Who Receives?

Is there any other income from any other source? *
YesNo

Yearly Amount

Source(s)

Who Receives?

Rental Income (apartment, ga- rage, land, etc.) *
YesNo

Monthly Amount

Type of Rental

Who Receives?

Room/Board (received) etc. *
YesNo

Monthly Amount

Name of Roomer/Boarder?

Who Receives?

Worker’s Compensation *
YesNo

Weekly Amount

Who Receives?

Unemployment Benefits *
YesNo

Weekly Amount

Who Receives?

Contribution (from someone outside household) *
YesNo

Weekly Amount

Name of Contributor

Who Receives?

Child Support Received *
YesNo

Court Ordered Weekly Amount

Source

Who Receives?

I fully understand that the Dr. Ann Stadelmaier Hearing Aid Fund services are limited to persons unable to pay, or who do not receive assistance from other sources. In consideration for such services, I hereby release and discharge all persons rendering such service from any claims that might arise from services or assistance provided. I understand that all information provided will be treated confidentially in accordance with HIPAA regulations. I give consent to release the minimum necessary information to additional sources that may assist in the funding of this hearing aid.

Signature of Applicant, Parent or Guardian *

Date *