District 33-A
Lions Sight & Hearing
Conservation & Treatment
Fund, Inc.
Application for Assistance Code #_________
Recommended steps in presenting a Sight & Hearing Case:
- The sponsoring club needs to evaluate/investigate the need of the applicant and accept the case. They must also determine what, if any, club funds can be contributed to this request.
- The sponsoring clubs Board of Directors must approve this case and minutes of the Board of Directors meeting must accompany the request for assistance.
- The sponsoring club must brief the Sight & Hearing Zone Representative on the case. The representative should:
- Check the form for completeness.
- If acceptable, then contact the Sight & Hearing President stating that the representative is presenting a case for acceptance at the next meeting.
- The Zone Representative presents the case to Sight & Hearing. The Zone Representative will determine who, if anyone, will be present at the presentation of the case to Sight & Hearing. The Zone Representative may perform the tasks necessary in steps 1-3 if no sponsoring club is found.
- The
applicant or designated person should complete the information requested
as completely as possible. Any additional information or clarification
will be requested by telephone or a personal visit. A telephone number
where the applicant can be reached must be included. The following
information
is required before a case may be
submitted to Sight and Hearing Fund.
INFORMATION TO BE COMMUNICATED TO ALL PARTIES
Do not bargain with Doctors or Hospitals! Leave that to the Sight & Hearing Fund Directors.
Do not pay any money to Doctors or Hospitals! If the applicant and/or Club is contributing any money towards this case, turn all information and monies over to the Fund, who, in turn, will pay all bills. If the case is approved this method of operation will give the Fund a greater bargaining power.
The following personal
information on this page will only be seen by the Case Representative and The
S&HF Treasurer.
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Please print
Name of Applicant: ___________________________________________________Date: _________________
Applicants Residence. _______________________________________________________________________
__________________________________________________________________________________________
Phone: ___________________________ Date of Birth: ________________ Marital Status: _______________
If minor, Parent of Guardian’s name: ___________________________________________________________
Applicant’s Signature________________________________________________________________________
Revision 2/07
District 33-A
Lions Sight & Hearing
Conservation & Treatment
Fund, Inc.
Application for Assistance
Code #______________Case #_________________
Assigned by Zone Rep. Assigned by S & H
President
Sponsoring Club: _____________________________________Region: _____________ Zone: ____________
Description of request: ______________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Medical Information:
Medical Insurance Provider: __________________________________________________________________
Address: __________________________________________________________________________________
Phone: __________________
Other Agencies providing assistance: ___________________________________________________________
Total amount of assistance: _____________ Number of Family members in the household: _______________
Employment (Applicant of Guardian): If not currently employed, list last employer.
Employer’s name & address: __________________________________________________________________
__________________________________________________________________________________________
____________________________________________________________ Phone: _______________________
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Last year’s Federal Income Tax return can be furnished in lieu of the following information:
NET WORTH STATEMENT CASH FLOW
STATEMENT
Assets
- current balances INFLOWS
– income
Cash and Bank Accounts ____________ Monthly
Earnings ____________
Savings total ____________ Alimony ____________
Checking Total ____________ Interest/Dividends ____________
Other ____________ Other ____________
Total cash accounts ____________ Total Inflows ____________
Other
Assets OUTFLOWS-
Expenses
Home ____________ Monthly food ____________
Automobile ____________ Monthly Auto ____________
Other ____________ Monthly
Utilities ____________
Monthly Insurance ____________
Total
other assets: ____________
Home Mortgage/Rent ____________
Home Repair allowance ____________
Investments
Monthly property tax ____________
Stocks/CDs ____________ Miscellaneous ____________
Other ____________ ____________
Total
Investments ____________ ____________
TOTAL
ASSETS: ____________ TOTAL OUTFLOWS ____________
LIABILITIES
– current
outstanding balances.
Mortgage ____________
Auto Loan ____________ TOTAL INFLOWS less
OUTFLOWS ____________
Other Loan ____________
Credit Card Balances ____________ TOTAL ASSETS less
LIABILITIES _____________
Subtotal of liabilities ____________
TOTAL LIABILITIES ____________
By submission of this request, the applicant authorizes the District 33-A Sight & Hearing Fund and/or the sponsoring Lions Club to verify any statements contained herein with any insurer, hospital, doctor, or any other party, an to receive any and all diagnosis and test results. Your signature on the front of this form and your initials below will attest to your having read, understood and agreed upon the above statement.
__________________________
Initials of Applicant or Guardian
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Lions Information
Region requesting
assistance: _____________ Sponsoring Lions Club: ________________________________
Region Advisor:
____________________________________________________________________________
Comments by Club or
Advisor: ________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Total estimated cost ________________________
Total amount of other
assistance ________________________
Amount Lions Club will
contribute ________________________
Amount available from
applicant ________________________
Amount requested from Sight
& Hearing Fund ________________________
_____________________________ ____________________________
Signature of Club President Signature
of Club Treasurer
Review by Sight and Hearing
Fund
Date application received:
________________________________ Reviewed by SHF: ____________________
Action taken by SHF:
________________________________________________________________________
_____________________________________________________
Date action taken: _____________________
Amount of request approved:
_____________________________ Date case closed: _____________________
Comments:
________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
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