Application for Assistance with Eye Glasses Contact Information Name * First Name Last Name Personal Email Home Address * This is your physical / 911 address. Not your mailing address (if different). Address 1 Address 2 City State/Province Zip/Postal Code Country Personal Phone (###) ### #### Employment Information Currently Employed * Are you currently employed? Yes No Employer Occupation Employer Phone (###) ### #### Years Employed Financial Information Salary / Month If you are currently employed, enter your monthly salary. If not employed, leave blank. $ Other Income * Do you have income from any other sources? Yes No Additional Income If you answered yes to Other Income enter amount here. If no other income, leave blank. $ Charity Assistance * Do you receive any financial assistance from a charity? Yes No Charity Income If you answered yes to Charity Assistance, enter amount here. If no charity assistance is given, leave blank. $ Expenses Rent or House Payment (Monthly) $ Transportation (Monthly) $ Utilities (Monthly) $ Cable / TV (Monthly) $ Telephone / Cell (Monthly) $ Insurance (Monthly) $ Food (Monthly) $ Medical (Monthly) $ Miscellaneous (Monthly) $ Insurance Do you have medical or other insurance? * Yes No Plan Name Policy / Claim / Case No Group Number Effective Date MM DD YYYY End Date MM DD YYYY Assistance Needed Request Estimated Cost $ Do you have Medicare? * Yes No Do you have Medicaid? * Yes No Thank you for your submission.One of our Lions will respond to your request within 5 five business days. If you don’t have a response after five business days you may contact us using the email below.