SAMPLE - FICTIONAL DATA

April 21, 2025

Patient Financial Services, Seaside Regional Hospital

Subject: Application for financial assistance

I am applying for financial assistance. My household has 3 people and our yearly income is $58,000.00, which is 212.3% of the 2026 federal poverty guidelines.

Your Financial Assistance Policy, Revised May 2026 lists a 90% discount at this income level.

The completed Financial Evaluation Form and the documents it lists are attached.

Attached: Financial Evaluation Form (filled, sign before sending); Documents listed in Table C of the form

Sincerely,

Daniela Castillo
9349 Seagrape Ln Apt 717
Bayside, FL 33067
(954) 555-0161