Fillable Hardship-waiver-form FM memo template

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Hardship-waiver-form FM memo template

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U.S.A. forms for City of Long Beach California

BROWSE CITY OF LONG BEACH CALIFORNIA (CA) FORMS

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City of Long Beach
Working Together to Serve
Declaration Supporting Waiver of Fee Owed Based on Hardship
Please fill out this form stating all of the reasons that you are unable to pay the fees that you owe the City
of Long Beach. Provide as many details as possible explaining why you cannot pay the amount owed, such
as job loss, medical condition, or the like. Also, indicate the amount that you can pay, if any. Please sign
and date this declaration in the space provided.
Return this form along with a copy of your last IRS W2 form and most recent bank statement to our office.
Please feel free to redact your social security number and/or bank account number from any documentation
submitted and doing so will not adversely impact our consideration of your request.
Please mail to City of Long Beach, Attn: Ambulance Billing, P.O. Box 22600, Long Beach, CA 90801 or
email AmbulanceBilling@LongBeach.gov.
I, ______________________________, Declare:
(Patient Name)
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(You may continue the declaration on a separate document if necessary)
I declare under penalty of perjury under the laws of the State of California that the foregoing is true
and correct, and that this declaration was executed on ___________________ in
________________________________, California.
(Date)
(City)
__________________________________________ Run #________________________
(Signature of Patient, Guarantor, Parent, or Guardian) (Located on bill, under Patient Name)
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Hardship-waiver-form FM memo template

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Completed 13 July 2020

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