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Memorial Hospital and affiliates, PO Box 160, Carthage, IL 62321, (217)3576591 Application for Determination of Eligibility for Financial Assistance Important: YOU MAY BE ABLE TO RECEIVE FREE OR DISCOUNTED

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Individuals or families who are seeking financial assistance from the organization or agency that requires form-5157-financial-assistance-application.

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What is form-5157-financial-assistance-application?

Form-5157-financial-assistance-application is a form used to apply for financial assistance.

Who is required to file form-5157-financial-assistance-application?

Individuals seeking financial assistance are required to file form-5157-financial-assistance-application.

How to fill out form-5157-financial-assistance-application?

Form-5157-financial-assistance-application can be filled out by providing personal, financial, and other relevant information as requested on the form.

What is the purpose of form-5157-financial-assistance-application?

The purpose of form-5157-financial-assistance-application is to request financial assistance from the appropriate authority.

What information must be reported on form-5157-financial-assistance-application?

Form-5157-financial-assistance-application requires information such as income, expenses, assets, liabilities, and any other pertinent financial information.

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