PHP Outpatient Scholarship Application - North Carolina Medical Society

NCPHP

Outpatient Treatment Scholarship

Application

Section 1: Biographical

Last 4 digits of Social Security Number*

Birthdate: (MM/DD/YYYY)*

Section 2: Financial

EMPLOYMENT INFORMATION

Are you currently working?

Yes

No

*

If not, what was the last date worked?

Expected return date:

FINANCIAL DETAILS

Your gross income last year:*

Number of members in household:*

Is your spouse/partner currently employed?

Yes

No

Not applicable

*

Spouse/partner's gross income from last year:

Do you rent or own your home?

Rent

Own

*

What are your MONTHLY household debt expenses? (If not applicable or if there are none, please enter $0 in the appropriate field.)

Monthly mortgage/rent costs:*

Car(s) Loans:*

Student Loans:*

Business Loans:*

Credit Card(s):*

Other debt:

What liquid assets are available for use in treatment? (If not applicable or if there are none, please enter $0 in the appropriate field.)

Savings:*

401(k)*

Investment portfolio*

Are other financial resources available to assist you?

Yes

No

If yes, please explain:

Please describe your financial circumstances to help us understand your situation:

Financial circumstances:

Section 3: Outpatient Therapy Information

Treatment Center Name*

Therapy Provider Name:*

Address:*

City*

Dropdown list*

Zip Code*

Phone:

Contact name:

Date therapy begins:

(Must have firm therapy start date to qualify for scholarship.)

Section 4: Attestation

By checking the box below, I declare, to the best of my knowledge and belief, that the above information is true, correct, and complete.

I agree.*