Yes, Let’s Go! We are excited to see that you may qualify for the SOLF program. Please fill the below information to let us know more about yourself and your financial aid qualifications.Personal InformationApplicant's Name* First Middle Last Email* Phone*Date of Birth* Date Format: MM slash DD slash YYYY Social Security Number*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Gender*MaleFemaleMarital Status*MarriedSingleDivorcedWidowedSeparatedWhat is your highest level of education completed?Preferred Spoken Language*EnglishSpanishDo you require an interpreter for medical/wellness visits?YesNoPrimary Care PhysicianPhysician Phone NumberCurrent EmployerEmployer Phone NumberHow long have you been employed there? (years/months)HouseholdHousehold is defined as all those who live together or are dependent on each other.Number In Household*12345List of names/ages of individuals other than yourselfPlease list each individual on a separate lineHealth InformationWhat health insurance company provides your coverage?Does your health insurance offer a benefit for hearing aids?YesNoDo you have any physical and/or diagnosed mental disability?YesNoIncomeList all sources of income (i.e. salary, social security, alimony, child support, pension, stocks, bonds, etc.) for all in household.Your Income*Please list each source of income on a separate lineSpouse/Partner IncomePlease list each source of income on a separate lineIf there are additional income earning residents in your household, please list herePlease list each source of income on a separate lineDo You Currently Have Any of the Following?*Please check all items that apply. Inaccurate responses will delay the process. Checking Account (if yes, provide all pages of three (3) months statements Savings Account (if yes, provide all pages of three (3) months statements CD(s) (if yes, provide most recent statement Stocks/Bonds (if yes, provide most recent statement Annuity (if yes, provide most recent statement IRS/401k (if yes, provide most recent statement Money Market Account (if yes, provide most recent statement Burial Account (if yes, provide most recent statement Are you a Medicaid Recipient? (if yes, provide most recent statement Do you receive any of the following?Please check all items that apply. Supplemental Security Income (SSEI) or Social Security Disability Income (SSDI) Medicaid HEAT (Home Energy Assistance Target Program) Lifeline (emergency phone service) Aid to Families with Dependent Children (AFDC) Emergency Work Program Food Stamps Refugee Assistance Temporary Assistance to Needy Families (TANF) Work Toward Employment Federal Public Housing assistance, including Section 8 Housing National School Lunch Free Lunch Program General Assistance (single adults or married couples without children who are unable to work because of a short or long-term disabling condition) Financial DocumentationIn determining eligibility, Sound of Life Foundation considers the following: Funds available from all sources, assets and hearing loss. Household size (household is defined as those living together or dependent of each other) Net Monthly or Annual Income from all in the household who have income. Possible Sources of income are: - Social Security - Public Assistance - AFDC - Wages - Interest from Stock - SSI - Alimony - Disability - Pension - IRA's, 401(k)s - VA Pension - Welfare - Black Lung Payments - Child Support Assets (include, but are not restricted to) - Checking - Annuities - Savings - Stocks/Bonds - Money Market Accounts - IRS/401(k) - CD's - Burial Accounts - Reverse Mortgage - Home Equity Loan - Property Sound of Life Foundation reserves the right to change eligibility criteria without prior written notice. Documents that must be submitted in order to proceed: - Copy of Driver's License or State ID - Copy of the 2 most recent paystubs (if employed) - Copy of last 3 months bank statements - Copy of IRA/Investment Income/401k, Stocks/Bonds, or other assets (if applicable) - Copy of Proof of Residence (utility bill, lease, other) - Proof of Social Security of Disability Income (if applicable) - Proof of Unemployment Income (if applicable) - Proof of government financial assistance or Food Stamps (if applicable) - Letter of Denial of Benefits (Medicaid, Insurance or Financial Aid) if applicable - Letter of Outstanding circumstances or Medical Expenses - Income verification filed out for all those in household - Hearing test result from Audiologist or Hearing Instrument Specialist within 6 monthsPlease upload all relevant statements based on your answers above.*HELPFUL HINT: If you do not have a digital copy of the required documentation, you have several options including: 1. Go to your local library or ask a friend to scan it for you. 2. Photograph the required documents or pages using your cell phone and upload the images. 3. Go to the program overview page and download an application to be completed and mailed in. A downloadable copy will be available on the program overview page. Drop files here or Other InformationHow did you first hear about the Sound of Life Foundation (SOLF)?*Web / Google searchCurrent SOLF ParticipantFamily / Friend told me about itLink from another websitePrimary Care DoctorAudiology ClinicMagazineOtherWhat key words were typed in the search?Please tell us the name of the person who referred you.Please give us the URL of the website that referred you.Please give us the name of the Doctor that referred you.Please give us the name of the clinic that referred you.Please give us the name of the magazine that referred you.Please specify who or what referred you.Have any family members applied to SOLF?*YesNoDisclosureI understand that the information I submit to the Sound of Life Foundation concerning my annual income, family size, family resources, insurance, medical history and all financial information is subject to verification by SOLF. I understand that if I knowingly omit or submit false information, I will be denied consideration for assistance at any point during the process. I understand that SOLF reserves the right to change eligibility criteria without prior written notice. I understand that when eligibility is determined, my financial documents are shredded. I understand that SOLF will never sell or share names and addresses with others. I understand that if I do not qualify that the $300 program fee will be returned to me, but the $50 non-refundable application fee will not be returned. I understand that if I am approved, I will receive hearing devices (if custom devices are required they are an additional charge), 1-year repair warranty through Sound of Life (loss and damage not covered), 1 fitting visit with a partnering audiology clinic, and 2 follow up visits. I understand that I will receive 1 year of batteries and supplies (a 6 month supply provided at fitting/follow-up appointment and the remaining 6 month supply will be mailed to address listed in application). I understand that I can reapply for new devices in 5 years. I understand that I may be asked to provide a digital photo and testimonial in order to further help others learn about the SOLF program. I agree I disagree A non-refundable $50 fee is required to process your application. Please submit this payment on the page that follows.Signature*Date* Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.
