APPLICATION FOR FINANCIAL ASSISTANCE. The application to LIC for financial assistance for the aforesaid purposes and the information furnished by the Company to LIC from time to time, is true and correct and shall be deemed to form part of the representations and warranties on the basis of which LIC has agreed to subscribe to the privately placed debentures.
APPLICATION FOR FINANCIAL ASSISTANCE. PATIENT INFORMATION Patient Name Age Telephone No. Patient No. Home Address Rent 🞎 Own 🞎 Live with parents? No 🞎 Yes 🞎 SSN Marital Status Discharge diagnosis If pregnant, due date? Name & Address of employer Employer Telephone No. How long employed? Position/Title Supervisor’s Name If unemployed, last date & place of employment Position/Title RESPONSIBLE PARTY INFORMATION Name Relationship to patient Age Telephone No. Street address, if different from patient SSN Marital Status Family Size Names & Ages Name & Address of Employer How long employed? Employer Telephone No. Position/Title Supervisor’s Name If unemployed, last date & place of employment Position/Title Name of Nearest Relative Relationship Address Telephone No. SPOUSE INFORMATION Name Age SSN Name of Employer Employer Address How long employed? Employer Telephone No. Position/Title Supervisor’s Name If unemployed, last date & place of employment Position/Title MONTHLY INCOME ASSETS ITEM 🞎 Patient 🞎 Spouse 🞎Father 🞎 Mother 🞎 Patient 🞎 Spouse 🞎Father 🞎 Mother 🞎 Patient 🞎 Spouse 🞎Father 🞎 Mother Checking Account(s) – bank & account number Balance Base Income Overtime Savings Account(s) – bank & account number Balance Social Security Interest/Dividends Other (bank & account number, money market, CD, IRA) Balance Rental Income Alimony/Child Support Life Insurance (company & policy number) Value Unemployment State Assistance Stocks, Bonds & Mutual Funds (company) Value Food Stamps Pension Automobiles/Trucks (make, model & year) Value Disability Worker’s Compensation Other Other Assets (personal, livestock, machinery, motorcycles, RVs) Value Real Estate (list and describe) Present Value TOTAL TOTAL ASSETS PLEASE COMPLETE THE INFORMATION AS THOROUGHLY AS POSSIBLE SO THAT AN ACCURATE ASSESSMENT OF YOUR CURRENT FINANCIAL SITUATION CAN BE DETERMINED. ALONG WITH THE FINANCIAL STATEMENT, AT LEAST TWO OF THE FOLLOWING ITEMS ARE REQUIRED FOR REVIEW. PLEASE PROVIDE THE FOLLOWING ITEMS:
APPLICATION FOR FINANCIAL ASSISTANCE. In the event any payment owing by the Company under this Section shall not be paid on demand by the Agency, such payment shall bear interest from the date of such demand at a rate equal to one percent (1%) plus the Prime Rate, but in no event at a rate higher than the maximum lawful prevailing rate, until the Company shall have made such payment in full, together with such accrued interest to the date of payment, to the Agency (except as otherwise specified above). The Agency shall be entitled to deduct all reasonable out of pocket expenses of the Agency, including, without limitation, reasonable legal fees, incurred with the recovery of all amounts due under this Section 4.8, from amounts received by the Agency pursuant to this Section 4.8.
APPLICATION FOR FINANCIAL ASSISTANCE. If the plan sponsor of a plan determines that the plan’s resource benefit level for an insolvency year is below the level of benefits guaranteed by PBGC or that the plan will be unable to pay guaranteed benefits when due for any month during the year, the plan spon- sor must apply to PBGC for financial assistance pursuant to section 4261 of ERISA and in accordance with § 4281.47 of this chapter.
