SAMPLE - FICTIONAL DATA

October 27, 2026

Patient Financial Services, Lakeview Demo Hospital

Subject: Application for financial assistance

Dear Patient Financial Services team,

I am applying for financial assistance. My household has 3 people and our yearly income is $61,000.00, which is 223.3% of the 2026 federal poverty guidelines.

Your Financial Assistance Policy lists a 90% discount at this income level.

The completed Financial Evaluation Form and the documents it lists are attached.

Attached: Financial Evaluation Form; Documents listed in Table C of the form

Sincerely,

Maria Sample
12 Example Lane
Riverton, ST 12345
(555) 010-0199