- Answer ALL of the questions on the following two pages:
Download the financial assistance application here
- Proof of gross year to date total income for ALL adults in the home: Need 3 most recent payroll stubs with year to date total income, beginning of year pension award letter, beginning of year social security award letter. Print outs of monthly amounts for; Unemployment income, child support, alimony, and food stamps.
- Self Employed Individuals please fill out self-employment balance sheet, this is required in order to process your application. Provide a complete listing of all assets (equipment, livestock, etc) and value of the assets.
Download the self-employment balance sheet
- Provide a COMPLETE copy of most recent FEDERAL TAX RETURN (1040) WITH ALL SCHEDULES ATTACHED.
Download Federal Tax Return (1040)
- If you did not file taxes, please explain why?
- If your taxes are self-prepared please request copy from IRS at 800-829-1040 or sign, date and return 4506-T form to us we can request it for you.
- If not employed please provide written statement explaining:
- Why are you unemployed? How do you pay for living expenses?
- When will you return to work?
- Do you qualify for unemployment benefits?
- If someone else is supporting you, please have the person or persons write a letter to explain. That letter should be signed, dated and notarized by your supporter.
- If you are a full time college student and receive any type of student loans, grants, scholarships, financial help from family members etc., that information HAS to be included. IF YOU ARE CLAIMED ON YOUR PARENTS TAX RETURN, a copy of their tax return and proof of their recent income is REQUIRED.
- Provide copies of documentation of the expense categories that apply to you (i.e. cable, phone, insurance, etc.)
- Do not include medical bills from PCRMC; only medical expenses from other providers. If other providers have granted you charity, we need to know the amount of charity you were approved for.
- SIGNATURES at the bottom of the Income & Expense worksheet are REQUIRED.
- Returns the application with all the appropriate documentation within 14 days.
- ALL applications returned without the appropriate information will be considered incomplete and not processed until all info is received.
- For Questions or further assistance to complete the application, please call (573) 458-7715 or 1-800-634-1404.
- To return the application by mail, please return it to:
PCRMC-ATTN Michelle M. – PFS
PO Box 220
- To return the application in person, please return it to:
- PCRMC, 1000 W. 10th St., Rolla, MO 65401
- Go to the Cashiers desk located in the main entrance of the hospital across from the gift shop.
Download form page 1 here