APPLICATION FOR FINANCIAL AID FOR EYEGLASSES



APPLICATION FOR FINANCIAL AID FOR EYEGLASSES

BELTON LIONS CLUB

The motto of Lions throughout the world is “WE SERVE.” The Belton Lions Club has served the Belton area since 1935 in numerous ways, including financial aid for the purchase of eyeglasses. If you wish to apply for financial aid for yourself, your child or another member of your immediate family you must meet all of the following criteria:

1. Be a resident of Belton (you must have a Belton address). Those who live in other cities or towns will be assisted by the Lions Club in that city or town.

2. Have a financial need due to limited income, size of family, age, disability, illness or other hardship. Those who are able to work but do not have a job or those who have a job with limited income will not be considered except in very unusual cases.

3. Have a visual problem which can be corrected by new eyeglasses.

4. Have not received assistance from the Belton Lions Club within the past three (3) years. Those who have received aid must wait a minimum of three years before receiving assistance again.

5. Have not received assistance from the Belton Lions Club more than three (3) times. Three times is the maximum you may be helped.

It is important to complete all the information on the back and attach proof of income or proof of disability if you are to be considered. If you need to supply additional information, please attach a separate page. You will be advised by letter within two weeks of your application if you have been approved for financial aid.

You must apply for assistance before purchasing your eyeglasses. The Belton Lions Club pays the optometrist for your glasses; we do not reimburse you for any amount you paid. If approved, you will be assigned to Dr. Eric Richardson. You must use this optometrist. You will need to select from a group of specified frames which have been approved by the Belton Lions Club.

For further information contact Rex Maynard at 338-7751.

Mail all applications to: Rex Maynard

PO Box 843

Belton, SC 29627

Or bring by Maynard’s Home Furnishings, 725 Anderson Street, Belton, S. C.

SIGHT CONSERVATION COMMITTEE

BELTON LIONS CLUB PO BOX 843 BELTON, SC 29627

Application for financial aid to obtain eyeglasses. Complete entire form. Attach proof of income (Social Security or Disability determination letter or check stub, payroll check stub or W2 form).

Applicant’s Name:___________________________________________ Age:___________

Street Address:________________________________________________________________, Belton, S. C. 29627

How many years have you lived in Belton?_______ Home Phone:_____________ Cell Phone:______________

Parents (if the applicant is a child):_________________________________________________________________

It is important that parents complete the rest of the application with their information.

School Attended (if the applicant is a child):______________________ Grade:________ Teacher:_____________

Are You Married?_______ Name of Spouse:__________________________________________________

Number of children and ages:____________________________________ Are you a single parent?__________

Do you have a job__________? If so, list your employer and income below.

Employer:__________________________________________________ Monthly Income:______________

Does your spouse have a job__________? If so, list their employer and income below.

Spouse’s Employer:__________________________________________ Monthly Income:______________

If you are employed, or are able to work, please explain why assistance is needed (medical hardship, number in family, limited income, other):

_____________________________________________________________________________________________

If you are unemployed, please explain why (retired, disabled, other):_____________________________________

_____________________________________________________________________________________________

If you do not work, what is your monthly income (list the amount beside your source of income):

Social Security *___________ Disability *___________ Retirement___________ Other_________________

* Must attach Social Security or Disability statement

Do you receive food stamps?______ Do you receive Welfare, and so how much per month?____________

Do you receive unemployment, and if so how much per month?_______________

Do you receive child support, and if so how much per month?_________________

Do you smoke?_________ Do you own a car?___________ Monthly Rent or House Payment:_______________

Other Major Expenses:___________________________________________________________________________

Reference (Pastor, Doctor or Friend):______________________________________ Telephone:_______________

Have you ever received aid from the Belton Lions Club?________ If yes, what year (or years)?_____________

I certify the above information is correct and I am not financially able to pay for new eyeglasses.

Date:___________________ ____________________________________________

Applicant

Be sure you complete the form in full and attach proof of income, Social Security statement or Disability determination letter!!!!

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