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

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