Request Assistance

APPLICATION FOR ASSISTANCE FROM THE SJO FUND
Please answer each question completely.

Patient Name

First Name

Last Name

Date of Birth

Address / City / State / Zip

Cell Phone

Work Phone

Marital Status of Patient

Single

Married

Separated

Divorced

Widowed

Church Affiliation

Type of Illness

Current Treatment

Patient's Doctor

Applicant's Employer

Health Insurance

Expenses Not Covered

Amount Requested

Enter $ amount:

Reason for the Request

List Other Aid Received

Date

Name of OFLC Member/Staff who referred you to the SJO Fund

Comments