Eyeglass Voucher Application New Form – Fill Out and Use This PDF

New Eyes Eyeglass Voucher Application Form

To be eligible for a voucher, applicants must:

1.Prove financial need (income at or below U.S. federal poverty guidelines) and provide proof of income or government assistance to Agency for verification.

2.Have had an eye exam within the past 12 months. Copy of prescription must be included.

3.Have no other resources to pay for glasses (including insurance, federal/state programs, other charitable support).

4.Have not received a New Eyes’ voucher within the past 24 months.

Please print clearly. Fully complete all sections. Incomplete and unsigned applications will not be processed and cannot be returned. You should allow up to 6 weeks for a voucher to be issued.

The voucher will be mailed to the agent listed below, not to the applicant.

Vouchers expire within 90 days of issuance.

ALL FIELDS MUST BE COMPLETED. DO NOT LEAVE BLANK OR APPLICATION WILL BE DISCARDED.

Agency Information

(Applicant’s case worker, social worker, health clinic or primary care doctor; NOT an eye doctor)

Agency Name

Phone #

Agency Address

City

State

Zip Code

Agency Representative Name

Email

(MANDATORY) Agency Tax ID:

Agent signature required on page 2.

Applicant Information

Applicant Name

Phone #

Date of Birth

Age_

Sex

If a Minor, Parent/Guardian’s Name

Address

Email

_______

City

State

Zip Code

Occupation

Employer

County________________________________________

Do you have:

Private Health Insurance?

Medicare? Medicaid? Other Public Assistance? (circle all that apply)

(Application form continued on page 2)

Mail completed form and COPY of eyeglass prescription to:

New Eyes • P.O. Box 332 • Short Hills, NJ 07078

Phone 973.376.4903

www.new-eyes.org

New Eyes Eyeglass Voucher Application

Page 2

YOUR FINANCIAL SUMMARY

Number of Family Members Living in the Household: # Adults

# Children

Monthly Household Income

Average Monthly Household Expenses

Applicant’s Take-home Pay

$_____________

Rent/Mortgage

$

Spouse’s Take-Home Pay

$_____________

Food

$____________

Parent/Guardian’s Take-Home Pay

$_____________

Utilities

$

Social Security Benefits

$_____________

Telephone/Cell Phone

$

Disability Benefits

$_____________

Medical Expenses

$

Retirement/Pension Benefits

$_____________

Car/Transportation

$

Veteran’s Benefits

$_____________

Insurance: Medical

$

Unemployment Benefits

$_____________

Home

$

Federal or State Public Assistance

$_____________

Life

$

Child Support/Alimony

$_____________

Credit Card Payments

$

Food Stamps

$_____________

Child Care

$

Other Income

$_____________

Other Expenses

$

Total Monthly Income

$_____________

Total Expenses

$

I verify that the financial information provided by this applicant is accurate.

Signature of Agency Representative (as named on page 1)

Date

IMPORTANT – PLEASE COMPLETE BELOW.

1.Please explain any unusual financial situation or other circumstance that might be helpful in reviewing this application.

2.Please tell us how a new pair of eyeglasses might make a difference to your life.

Attach an additional sheet if necessary.

I certify that the information I provided is true and accurate to the best of my knowledge.

Signature of Applicant (or Parent/Guardian)

Date

[ ] CHECK ALL SECTIONS ARE COMPLETED & A COPY OF THE EYEGLASS PRESCRIPTION IS ATTACHED.

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