Financial Assistance Application

Please correct the errors described below.

Living Bread Greenville

A completed financial assistance application and proof of income must be submitted in order for us to consider you for our financial assistance program.

Financial assistance is available for ongoing treatment costs (e.g., therapy or nutrition sessions). Reimbursement for bills already paid is not available.

Financial assistance for counseling is only available at the Living Bread Counseling Center. Please sign a release for your therapist to be able to communicate with the board of directors of the Living Bread.

Part 1: Applicant Information

Date of Application

Last Name

First Name

Middle Initial

Date of Birth

Email address

Do you have dependents? Other than yourself & Co-Applicant

Yes No

Number of Dependents

Ages of Dependents

Home Phone

Is this a mobile phone?

Yes No

Mobile Phone

Work Phone

Street Address

City

State

ZIP

Are you currently employed?

Yes No

Current Employer Name

Employer Full Address

Job Title

How long have you been unemployed?

Part 2: Co-Applicant Information (Optional)

Do you have a Co-Applicant? Spouse, parent/guardian, or anyone else contributing to applicant's income.

Yes No

Co-Applicant Last Name, First Name, Middle Initial

Co-Applicant Date of Birth

Does your Co-Applicant have dependents? Do not include those already claimed by applicant

Yes No

Number of Dependents

Do not include those already claimed by applicant

Ages of Dependents

Home Phone

Mobile Phone

Work Phone

Street Address

City

State

County

ZIP

Current Employer

Enter "N/A" if currently unemployed

Employer Full Address

Enter "N/A" if currently unemployed

Job Title

Enter "N/A" if currently unemployed

If you are not working, how long have you been unemployed?

Enter "N/A" if currently unemployed

Part 3: Income Information

Please select each type of monthly income sources you have

Employment Income

Social Security

Disability

Unemployment

Other Government Aid

Spousal/Child Support

Rental Property

Investment Income

Other(s)

None

Applicant Employment Income

Co-Applicant Employment Income

Enter "N/A" if no Co-Applicant or if no Co-Applicant Income

Combined Monthly Employment Income

Applicant Social Security Income

Co-Applicant Social Security Income

Enter "N/A" if no Co-Applicant or if no Co-Applicant Income

Combined Monthly Social Security Income

Applicant Disability Income

Co-Applicant Disability Income

Enter "N/A" if no Co-Applicant or if no Co-Applicant Income

Combined Disability Income

Applicant Unemployment Income

Co-Applicant Unemployment Income

Enter "N/A" if no Co-Applicant or if no Co-Applicant Income

Combined Unemployment Income

Other Government Aid Income

Co-Applicant Other Government Aid Income

Enter "N/A" if no Co-Applicant or if no Co-Applicant Income

Combined Other Government Aid Income

Applicant Spousal/Child Support

Co-Applicant Spousal/Child Support

Enter "N/A" if no Co-Applicant or if no Co-Applicant Income

Combined Spousal/Child Support

Rental Property Income

Co-Applicant Rental Property Income

Enter "N/A" if no Co-Applicant or if no Co-Applicant Income

Combined Rental Property Income

Investment Income

Co-Applicant Investment Income

Enter "N/A" if no Co-Applicant or if no Co-Applicant Income

Combined Investment Income

Enter any other types of income and monthly amounts

Do your parents or guardian help you financially in any way not yet listed?

Yes No

Please list the amount of assistance and how the money is used.

Total Combined Monthly Income

The total of all income sources above.

If you do not have monthly income, please explain how you take care of your monthly expenses.

Part 4: Assets

Do you have a Checking, Savings, or Money Market Account?

Yes No

Please select the type of account

Bank Name

Current Balance

List all available funds

Do you have an additional Checking, Savings, or Money Market Account?

Yes No

Please select the type of account

Bank Name

Current Balance

List all available funds

Please list any additional bank accounts here. Include Account Type, Bank Name, and Current Balance.

Part 5: Estimated Monthly Living Expenses

Rent/Mortgage Payment

Property Taxes (if not included in mortgage payment)

Homeowner's Insurance (if not included in mortgage payment)

Utilities (Electricity, Gas, Water, Garbage, Recycling, etc.)

Food

Telephone (home and mobile)

Child Support

Spousal Support/Alimony

Child Care

Credit Cards

Health Insurance Premiums

Current outstanding bills for medical, dental, or prescriptions

Total Monthly Automobile Payment(s)

Automobile Insurance

Automobile Gasoline

Liens/Wage Garnishments

Other Expenses

You may also use Part 6 below to document any additional expenses

Total Monthly Expenses

The total of all expenses listed above

Part 6: Additional Information & Comments

Enter any additional information or comments here

Part 7: Financial Assistance Questions

Is the applicant applying for financial assistance with therapy at the Living Bread Counseling Center?

Yes No

Frequency Requested

Name of therapist

Does your insurance reimburse you for a percentage of out-of-network therapy costs?

Yes No

If yes, what percentage?

Name of Insurance Company

Is the applicant applying for assistance with costs for nutritional counseling?

Yes No

Frequency Requested

Name of Nutritionist

Is the applicant also participating in a higher level of care, such as an Intensive Outpatient Program?

Yes No

Please indicate the weekly amount you must pay (your copay)

Is the applicant applying for assistance with medical monitoring by a physician?

Yes No

How frequently do you need medical follow-up appointments?

Physician's Name

Please indicate amount paid by you to physician (co-pay) per visit

Once you've completed this application, you must submit proof of income. Proof of income may be pay stubs, tax forms, or other forms if approved by the Financial Assistance Committee. You may either upload the attachments using the Upload a file link below, or you may email the attachments to FAC@livingbreadgreenville.org. No decision can be made until receipt of Proof of income.

Proof of Income Attachments

Add file

Please upload a file

I certify that all information is valid and complete and hereby authorize Living Bread to send available finances to the services I have listed on this application and send finances to future services for which I request financial assistance.

I, the Co-Applicant, certify that all information is valid and complete and hereby authorize Living Bread to send available finances to the services I have listed on this application and send finances to future services for which I request financial assistance.

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