Eyeglasses Assistance Program ... - Loveland Lions Club
[Pages:1]Eyeglasses Assistance Program Application
Loveland Lions Club
Instructions: 1) Prepare a separate application for each person needing assistance. 2) Print CLEARLY and ensure writing is LEGIBLE. 3) Complete each item or mark it as N/A (not applicable). 4) Use the back of the page OR attach additional page(s) if more space is needed to answer an item. 5) If homeless, ensure reliable contact information is listed so we can reach you. 6) Call Kay at 970-622-9799 if you have a question about completing the application. 7) Send completed application to LOVELAND LIONS, c/o EYEGLASS COMMITTEE, P.O. BOX 928, LOVELAND, CO 80539.
The Loveland Lions Eyeglass Committee will notify you by mail of the Committee's decision.
Referring Agency:
Staff Member:
Phone #
Name: Address:
Phone
Age
DOB
How long?
Mailing Address (If different)
If Minor, Parents Name:
Own home , Rent home Other:
, Homeless:
How long?
Single Married Divorced Other
Spouse `s Name if married:
Age:
List all vehicles you own? Makes, Models, Years?
List Names of Anyone Living with Applicant or Assisting Applicant:
Do you have Medicaid? Yes No Do you have vision insurance? No Yes What company? Have you previously worn glasses? Yes No What help are you seeking and why?
Applicant's Monthly Income
Combined Family Wages
Gross Income (before taxes and withholding)
$
Net Income (Take Home) $
Applicant's Monthly Expense
Rent/Mortgage
$
Life Insurance
$
Food (not including food stamps) $
Health Insurance $
Other Income/Assistance
Program
Monthly Amount Received
SSI
$
Utilities/Gas-Electricity-water $
How long receiving Benefit?
Telephone/cell
$
Cable/Satellite TV
$
Auto Insurance
$
Car Maintenance/Gas $
Auto Payments
$
ADC
$
Clothing
$
Storage
$
OAP
$
Unemployment $
Medical/Pharmacy
$
$
Dental
$
$
Other Income $ Food Stamp Assistance? Yes No
How much?
Loans/Credit Cards
Balance $
Payment $
Free-School Lunch Program? Yes No Date first issued.
$
$
$
$
TOTAL MONTHLY INCOME $
TOTAL MONTHLY EXPENSE:
$
I verify the above information is complete and accurate: X_____________________________________
Signature
Date Application Received:
Committee Meeting Date:
Applicant Notified: Date:
Exam: Approve Deny
Glasses: Approve Deny
Reason for Denial Comments:
__________
Date
Loveland Lions Club
Use back of page if more space is needed
July 2021
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- onesight onsite voucher program
- vision program patient packet lions lighthouse
- lions eyeglass recycling centers
- lions eyeglass application martyjuel
- usable glasses can make a difference home page lions
- application for glasses
- lions eyeglass recycling center guidelines
- eyeglasses assistance program loveland lions club
Related searches
- lions club application for eyeglasses
- lions club eye care assistance
- lions club eye care program
- lions club help with eyeglasses
- lions club free glasses program
- lions club baton rouge la
- lions club eye exam
- lions club eyeglass collection locations
- lions club vision assistance application
- lions club application form
- lions club assistance with glasses
- lions club eyeglass donation sites