Application Application/Verification of Financial Information Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Date / Time *DateTimeName *FirstLastYour Social Security # *Phone # *Email *Date of birth *month/day/yearAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDo you work Full Time or Part Time? *Full TimePart TimeHow Many Hours Do You Work Per Week? *Employer Name *Employer Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmployer Phone *Annual Income *Provide 2 months pay stubs and most recent W2. Upload photos below.File Upload - 2 Pay Stubs and most Recent W2 * Click or drag files to this area to upload. You can upload up to 4 files. File Upload - Proof of Address - property tax bill, utility bill, ect. * Click or drag files to this area to upload. You can upload up to 4 files. Housing *RENTOWNHOMELESSMarital Status *SingleMarriedWidowedDivorcedHow many people live in your home? *Please list every person living with you belowName of Person 2 Living in Home (other than you) *FirstLastSocial Security Number of person 2 living in home (other than you) *Name of Person 3 Living in HomeFirstLastSocial Security # of Person 3Name of Person 4 Living in HomeFirstLastSocial Security # of Person 4Name of Person 5 Living in HomeFirstLastName of Person 5 Living in HomeFirstLastName of Person 6 Living in Home FirstLastSocial Security # of Person 6 Living in HomeDo you or any members of your household receive any of the following benefits? If so, please provide a copy of the award statements for each, and list the monthly amount received . UnemploymentSocial SecurityChild SupportState SupplementalAlimonyWorker's CompDisability Kinship CareMedical AssistanceSNAPPlease list the monthly amount received from each below.Benefit Amounts *File Upload - Additional Benefit Award Statements Click or drag files to this area to upload. You can upload up to 4 files. Are other members of your household employed? *YESNOIf so, please provide 2 months' pay stubs and their most recent W2. What is their total annual income? List annual income in above box. Upload files below.File Upload - Other Members of Household (2 pay stubs & W2) Click or drag files to this area to upload. You can upload up to 2 files. You can take a photo of the pay stubs with your phone and upload the pictures here. Upload W2.What is you Your Total Household Income? All Employment Income + Benefits (listed above) *What is your Total Household Income?Do you have Dental insurance? *YESNo Do you have Health insurance? *YESNo Do you have Medicaid? *YESNo What is your Medicaid Number?How can we help you? Please describe your dental/medical needs: By submitting this application, I certify that the information contained in this form is true and correct to the best of my knowledge. I hereby grant permission for 5:16 Clinic and its agents to verify my employment, income, insurance coverage, Medicaid status and any other pertinent information needed to determine if I qualify for free dental and/or medical services. Submit Share this:TwitterFacebookLike this:Like Loading...