Lancaster Lions Club Application

Fill out both pages of the application completely, leave no blanks.

Return the completed application to Fairfield County 2-1-1 at 108 W. Main Street, Suite C, Lancaster, Ohio, 43130. Include the following documentation:

Proof of income for everyone in the household
Proof of address (example: a utility or phone bill)
Valid Picture ID & Social Security Card for all household members

NOTE: Your application will NOT be processed without ALL of the above mentioned documentation and it cannot be processed if there are any blanks on the application.

Once you have completed the application and provide Fairfield County 2-1-1 with all necessary documents, a caseworker will review the applications and submit it to the Lions Club for final approval.

This process can take up to 4-6 weeks.

When the caseworker receives an answer concerning your application, you will be contacted by telephone. Please make sure that a valid phone number is listed.

If you have any questions, please feel free to call Fairfield County 2-1-1 by dialing 2-1-1 or 740.687.0500.

Lancaster Lions Club Application

Applicant Name

(If Child) Legal Guardian’s Name

Phone #

Alternate Phone #

Address

City

Zip

Please answer the following questions to the best of your knowledge.

1. Do you have Medicaid?

Yes No

2. Do you have eye care insurance?

Yes No

3. What is the nature of your eye problem?

4. What is the reason you need an eye exam and/or glasses?

5. Do you currently wear glasses?

Yes No

6. If yes, date purchased

Doctor

7. Name of current eye doctor

8. What are you requesting from the Lions Club?

Glasses Exam Both

9. If glasses are needed, can you pay for the exam?

Yes No

10. Have you had an eye exam yet?

Yes No

11. Have you ever applied for glasses through the Lions Club?

Yes No

If yes, when was the date of the applications?

Were you approved or denied?

12. How many people live in your home?

Please list the names and ages of all people living in your home, including children

Name	Age

Lancaster Lions Club Application - Financial Information

13. What is your monthly income (Please list all sources)

Income Source	Applicant	Other Adult
Employment
ADC
SSI/SSID
Food Stamps
Other
Total Income

14. Name of employer

How long?

Name of previous employer

How long?

15. Please list all of your monthly expenses

Mortgage/Rent

Utilities

Electric

Car Payment

Gasoline (Auto)

Insurance (Auto/Home/Life)

Groceries/Household Goods

Phone (Home and Cell)

Cable/Internet

Health Insurance

Prescriptions

Doctor/Hospital Bills

Charge Cards

Other

Total Monthly Expenses

Comments

With my signature, I certify that the information contained within this application is true and accurate to the best of my knowledge. My signature also allows Fairfield County 2-1-1 permission to release information necessary to process this application.

Applicant’s Signature

Date

The information requested is required by the Lancaster Lions Club for their use in determining assistance based on this request. Approval and or denial of any and all request is based on availability of funding and at the discretion of the Lancaster Lions Club. Completion of this form does NOT guarantee approval of assistance. Any and all appointments and bills must be approved by the Lancaster Lions Club.

DISCLAIMER: Lenses provided are plastic lenses and we cannot provide lenses with anti-reflective coating and transition lenses with this program. You CANNOT pay the difference.

Lions Club Application Instructions

Lancaster Lions Club Application

Please list the names and ages of all people living in your home, including children

Lancaster Lions Club Application - Financial Information

13. What is your monthly income (Please list all sources)

15. Please list all of your monthly expenses