Laserfiche WebLink
APPENDIX 5 <br /> Patient's Name Contact Phone# <br /> Date of Service <br /> Transported to <br /> Responsible Party <br /> Name <br /> Relationship <br /> Current Employer <br /> Employed From <br /> Previous Employer <br /> Spouse Employer <br /> Employed From <br /> Previous Employer <br /> Income Family Member 1 Family Member 2 Family Member 3 Family Member 4 <br /> Name <br /> Relationship <br /> Wages <br /> Self Employment <br /> Public Assistance <br /> Social Security <br /> Unemployment <br /> Worker's comp <br /> Checking/Savings <br /> Child Support/Alimony <br /> Pension/Retirement <br /> Dividend/Interest Income <br /> Rental Prop. Income <br /> Other Income (detail) <br /> Total Income <br /> The above information is true and correct to the best of my knowledge. I authorize the City of Everett Fire <br /> Department to verify this information for the purpose of financial assistance eligibility determination. <br /> Signature (Patient or Responsible Party) Date <br /> Note: If you feel you have other pertinent information regarding your financial status, please list it on a <br /> separate sheet of paper and submit it with this form. <br /> OFFICE USE ONLY: <br /> Current account balance Adjustment(by Fire Dept.) New Balance <br /> Signature (Fire Department) Date <br /> 4 <br />