Instructions:
As part of our commitment to serve the community, NLGBA is committed to provide financial assistance so that the financial capacity of families who require medically necessary services does not prevent them from seeking or receiving care.
To determine if applicant qualifies for financial assistance, we need to obtain certain financial information. Your cooperation will allow us to give all due consideration to your request for financial assistance.
All applicants have certain responsibilities including:
• Honesty;
• Providing accurate and complete information in a timely manner so that NLGBA can process the
request for financial assistance;
• Responsiveness – provide timely follow-up for additional documents or information NLGBA requires for
the Financial Assistance Application process;
• Full disclosure of the required information;
Please provide the following information and copies of information with your Financial Assistance Application:
Documents to verify income:
a. Please provide one or more of the following:
• Wage & Earnings Statement
• Bank statement that contains income information (i.e. record of direct deposit, etc.)
b. Please provide a copy of one of the following:
• Government Assistance documentation, Social Security System
• Income tax return for previous year.
Applications without income verification are considered incomplete and will not be processed. For assistance in completing this application, please contact NLGBA at XXX-XXX-XXXX, Monday through Friday from 8:00 a.m. to 4:30 p.m. Please return the application and verification of income documents within seven (7) calendar days to:
Northern Luzon Gamefowl Breeders Association
Director of the Administrator
XXXX-XXXX
XXXX-XXXX
San Fernando, La Union
Please note that falsification of information may result in denial of the financial assistance application. If, after applicant is granted financial assistance, NLGBA finds material provision(s) of the financial assistance application to be untrue, the financial assistance may be withdrawn.
We will notify you of your eligibility following receipt and review of all necessary information. The notification will be mailed to the mailing address you have provided on the Financial Assistance Application. If you are not eligible for financial assistance, we will notify you.