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Document Checklist

For your Financial Assistance Application*, please review this Checklist.
 
You can submit COPIES of the following documents:
 
Proof of Residency in Santa Clara County – Provide ONE of the following:
 
  • Rental Contract/Lease
  • Mortgage Statement
  • Utility Bill (Water, Electric Gas, Garbage)
Proof of Identity (Photo ID Required) – Provide ONE of the following:
 
  • Driver’s License
  • Passport
  • Government-issued ID Card
  • Work or School ID Card
Proof of Income – Provide ALL that Apply:
 
  • Check Stubs (all stubs not older than 45 days from application date)
  • Tax Return (current tax year)
  • Award Letter (Social Security, Disability, Unemployment, Worker’s Compensation)
  • Cash Income Statements (including tips)
  • Military Benefits Statement
  • Rental Income Receipts
 
Proof of Assets – Provide ALL that Apply:
 
  • Bank Account Statements (last 3 months, all savings, checking, other financial accounts)
  • Investment/Asset Account Statements (IRA’s, CDs, 401 (k))
  • Money Market, Stocks Bonds, etc.
  • Cash-on-Hand
 
If Required – these documents must be ORIGINALS
 
Proof of US Citizenship or Permanent Residency – Provide an ORIGINAL of ONE of the following:
 
  • US Passport
  • US Birth Certificate
  • VISA
  • Certificate of Naturalization (N-550 or N-570)
  • US Permanent Residency (Green) Card
  • Certificate of Citizenship (N-560 or N-561)
 
* Depending on a person’s declarations and/or differences in documentation, additional documents may be required. If more documents are required, you will be instructed which documents to provide. You will also be given a deadline for returning additional documents to the SCVHHS Patient Access Department.
 
‡ Eligibility for some programs requires that a person provides proof of U.S. Citizenship or U.S. Permanent Residency.  If you are eligible for a program that requires proof of citizenship or permanent residency, you will be instructed to bring original documents (copies will not be accepted) to the financial screening interview.  Undocumented individuals may be eligible for programs that do not require proof of U.S. Citizenship or U.S. Permanent Residency.







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