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Reso 21-2024 (24-139)
Account- Run Number Date of Service Balance AB716 Max Adjusted Amount FF22-926 2/13/202 2 $2,350.00 $682.52 $682.52 EF21-4613 10/25/20 21 $2,328.00 $682.52 $682.52 EMS1905 7902 12/19/20 19 $2,230.00 $682.52 $682.52 EMS1901 2810 3/19/201 9 $2,001.00 $682.52 $682.52 EF22-4658 10/15/20 22 $2,218.00 $682.52 $682.52 EF23-282 1/18/202 3 $2,332.00 $682.52 $682.52 EMS1905 0006 11/1/201 9 $2,124.00 $682.52 $682.52 20170000 41 1/2/2017 $2,770.00 $682.52 $682.52 EF21-4984 11/18/20 21 $2,436.00 $682.52 $682.52 EMS2002 9272 7/20/202 0 $2,071.00 $682.52 $682.52 EMS1905 9539 12/29/20 19 $2,230.00 $682.52 $682.52 FF22-3647 6/30/202 2 $2,436.00 $682.52 $682.52 EF23-532 1/31/202 3 $2,446.00 $682.52 $682.52 EF22-3405 7/28/202 2 $2,218.00 $682.52 $682.52 EF22-4 1/1/2022 $2,328.00 $682.52 $682.52 EMS1902 2863 5/20/201 9 $2,664.00 $682.52 $682.52 EMS1905 8381 12/22/20 19 $2,230.00 $682.52 $682.52 EF22-296 1/16/202 2 $2,220.00 $682.52 $682.52 EF23-681 2/8/2023 $2,218.00 $682.52 $682.52 EMS1804 6193 10/15/20 18 $2,001.00 $682.52 $682.52 20160038 43 8/16/201 6 $2,405.00 $682.52 $682.52 EF22-809 2/14/202 2 $2,296.00 $682.52 $682.52 EMS2002 0698 5/17/202 0 $2,251.00 $682.52 $682.52 EF22-3924 8/28/202 2 $2,446.00 $682.52 $682.52 EF22-1802 4/22/202 2 $2,220.00 $682.52 $682.52 EF21-2392 5/31/202 1 $2,230.00 $682.52 $682.52 EF22-415 1/22/202 2 $2,760.00 $682.52 $682.52 EMS1903 5046 8/2/2019 $2,071.00 $682.52 $682.52 EF21-2900 7/5/2021 $2,283.00 $682.52 $682.52 EF21-3615 8/20/202 1 $2,389.00 $682.52 $682.52 EM21- 40303 10/3/202 1 $2,328.00 $682.52 $682.52 EF22-3352 7/23/202 2 $2,503.00 $682.52 $682.52 EF23-220 1/14/202 3 $2,503.00 $682.52 $682.52 EF21-1939 4/29/202 1 $2,283.00 $682.52 $682.52 EM22- 47387 10/9/202 2 $2,218.00 $682.52 $682.52 EF21-3407 8/9/2021 $2,124.00 $682.52 $682.52 EF21-4279 10/3/202 1 $2,436.00 $682.52 $682.52 20170013 17 3/13/201 7 $2,320.00 $682.52 $682.52 EMS1904 9216 10/27/20 19 $2,230.00 $682.52 $682.52 EF21-5066 11/23/20 21 $2,382.00 $682.52 $682.52 EF21-2781 6/26/202 1 $1,601.00 $682.52 $682.52 EMS2004 6489 11/15/20 20 $2,177.00 $682.52 $682.52 EF22-1851 4/25/202 2 $2,598.00 $682.52 $682.52 EM22- 32000 7/12/202 2 $2,275.00 $682.52 $682.52 EF22-533 1/29/202 2 $2,166.00 $682.52 $682.52 EF22-5329 11/23/20 22 $2,731.00 $682.52 $682.52 EMS1805 4371 12/5/201 8 $2,001.00 $682.52 $682.52 EMS2001 9432 5/7/2020 $2,389.00 $682.52 $682.52 EF22-771 2/12/202 2 $2,458.00 $682.52 $682.52 EF21-4605 10/24/20 21 $2,274.00 $682.52 $682.52 20170001 00 1/6/2017 $2,010.00 $682.52 $682.52 EF21-5105 11/25/20 21 $2,328.00 $682.52 $682.52 EF22-1850 4/25/202 2 $2,490.00 $682.52 $682.52 EMS1802 7816 6/21/201 8 $2,050.00 $682.52 $682.52 EF21-2281 5/24/202 1 $2,230.00 $682.52 $682.52 EF21-4684 10/28/20 21 $2,544.00 $682.52 $682.52 EMS1802 7316 6/18/201 8 $2,050.00 $682.52 $682.52 EF21-3629 8/22/202 1 $2,389.00 $682.52 $682.52 EF23-578 2/3/2023 $2,503.00 $682.52 $682.52 20170004 72 1/24/201 7 $2,010.00 $682.52 $682.52 EF21-3625 8/21/202 1 $2,283.00 $682.52 $682.52 36522440 1/14/201 6 $2,048.00 $682.52 $682.52 EF22-1255 3/15/202 2 $2,490.00 $682.52 $682.52 EF22-1425 3/27/202 2 $2,490.00 $682.52 $682.52 EF21-3487 8/13/202 1 $2,389.00 $682.52 $682.52 EF22-750 2/10/202 2 $2,328.00 $682.52 $682.52 EF22-544 1/30/202 2 $2,166.00 $682.52 $682.52 37503372 3/21/201 6 $1,978.00 $682.52 $682.52 EF22-683 2/6/2022 $2,328.00 $682.52 $682.52 EF22-950 2/23/202 2 $2,490.00 $682.52 $682.52 EF22-284 1/16/202 2 $2,328.00 $682.52 $682.52 ESF17002 556 6/16/201 7 $2,050.00 $682.52 $682.52 EF21-4592 10/24/20 21 $2,652.00 $682.52 $682.52 EF21-5198 12/1/202 1 $2,436.00 $682.52 $682.52 EF22-4851 10/26/20 22 $2,446.00 $682.52 $682.52 EF22-3437 7/30/202 2 $2,332.00 $682.52 $682.52 EF22-1820 4/24/202 2 $2,166.00 $682.52 $682.52 EF21-4483 10/16/20 21 $2,490.00 $682.52 $682.52 EF21-3641 8/22/202 1 $2,283.00 $682.52 $682.52 EMS1805 7908 12/26/20 18 $2,409.00 $682.52 $682.52 36832201 2/5/2016 $2,078.00 $682.52 $682.52 EMS2002 3994 6/11/202 0 $2,177.00 $682.52 $682.52 EF22-5000 11/3/202 2 $2,446.00 $682.52 $682.52 EMS1901 3544 3/23/201 9 $2,052.00 $682.52 $682.52 EM22- 27988 6/19/202 2 $2,296.00 $682.52 $682.52 20170002 18 1/11/201 7 $2,165.00 $682.52 $682.52 EF21-3166 7/24/202 1 $2,336.00 $682.52 $682.52 EF22-127 1/7/2022 $2,490.00 $682.52 $682.52 EF21-4794 11/5/202 1 $2,512.00 $682.52 $682.52 EF21-2824 6/29/202 1 $2,389.00 $682.52 $682.52 EMS1904 3494 9/23/201 9 $2,071.00 $682.52 $682.52 EF22-288 1/16/202 2 $2,490.00 $682.52 $682.52 EMS1801 2008 3/14/201 8 $2,670.00 $682.52 $682.52 EF21-4605 10/24/20 21 $2,274.00 $682.52 $682.52 EF22-4043 9/5/2022 $2,731.00 $682.52 $682.52 EF22-295 1/16/202 2 $2,112.00 $682.52 $682.52 EF22-3996 9/2/2022 $2,674.00 $682.52 $682.52 EF21-3475 8/13/202 1 $2,283.00 $682.52 $682.52 EF22-1066 3/2/2022 $2,328.00 $682.52 $682.52 EF22-256 1/15/202 2 $2,112.00 $682.52 $682.52 EF21-2233 5/20/202 1 $2,283.00 $682.52 $682.52 EF22-2290 5/21/202 2 $2,490.00 $682.52 $682.52 20160050 674 10/29/20 16 $2,110.00 $682.52 $682.52 EF21-3209 7/26/202 1 $2,230.00 $682.52 $682.52 EMS1802 1126 5/10/201 8 $2,050.00 $682.52 $682.52 EMS1805 5956 12/14/20 18 $2,103.00 $682.52 $682.52 EMS1804 1054 9/13/201 8 $2,001.00 $682.52 $682.52 EF21-3668 8/25/202 1 $2,283.00 $682.52 $682.52 20160037 41 8/10/201 6 $2,355.00 $682.52 $682.52 EM22- 55636 11/24/20 22 $2,332.00 $682.52 $682.52 EF22-3769 8/20/202 2 $3,016.00 $682.52 $682.52 20170000 50 1/3/2017 $2,165.00 $682.52 $682.52 FF21-1953 4/7/2021 $2,389.00 $682.52 $682.52 EMS2002 0729 5/18/202 0 $2,124.00 $682.52 $682.52 EF22-3149 7/9/2022 $2,617.00 $682.52 $682.52 EF21-4659 10/27/20 21 $2,328.00 $682.52 $682.52 EMS1904 1677 9/12/201 9 $2,304.00 $682.52 $682.52 EF22-5744 12/16/20 22 $2,503.00 $682.52 $682.52 EF22-399 1/22/202 2 $2,112.00 $682.52 $682.52 EF23-336 1/20/202 3 $2,332.00 $682.52 $682.52 EMS1803 1287 7/13/201 8 $2,154.00 $682.52 $682.52 16001961 4/25/201 6 $2,041.00 $682.52 $682.52 36674494 1/25/201 6 $2,118.00 $682.52 $682.52 20160049 18 10/20/20 16 $2,000.00 $682.52 $682.52 EF21-3440 8/11/202 1 $2,389.00 $682.52 $682.52 EF22-5912 12/24/20 22 $2,218.00 $682.52 $682.52 36576618 1/18/201 6 $2,218.00 $682.52 $682.52 EMS1804 0764 9/11/201 8 $2,256.00 $682.52 $682.52 EF22-178 1/10/202 2 $2,220.00 $682.52 $682.52 ESF17002 822 7/7/2017 $2,100.00 $682.52 $682.52 EMS1904 0515 9/4/2019 $2,124.00 $682.52 $682.52 EF22-955 2/23/202 2 $2,436.00 $682.52 $682.52 EF21-3436 8/10/202 1 $2,283.00 $682.52 $682.52 EF21-2768 6/26/202 1 $2,442.00 $682.52 $682.52 1804749 9/18/201 8 $2,307.00 $682.52 $682.52 ESF18003 383 8/10/201 8 $2,511.00 $682.52 $682.52 EF21-3245 7/29/202 1 $2,442.00 $682.52 $682.52 EF22-5680 12/13/20 22 $2,674.00 $682.52 $682.52 EF22-1681 4/14/202 2 $2,490.00 $682.52 $682.52 EF22-727 2/9/2022 $2,274.00 $682.52 $682.52 EMS1705 5898 12/17/20 17 $2,150.00 $682.52 $682.52 EMS1805 5285 12/10/20 18 $2,634.00 $682.52 $682.52 EF21-3941 9/11/202 1 $2,442.00 $682.52 $682.52 EMS1901 3133 3/21/201 9 $2,052.00 $682.52 $682.52 EF22-515 1/28/202 2 $2,382.00 $682.52 $682.52 EF21-3202 7/26/202 1 $2,283.00 $682.52 $682.52 EM21- 30561 8/1/2021 $2,707.00 $682.52 $682.52 EF21-5606 12/26/20 21 $200.00 $682.52 $200.00 EF22-1240 3/13/202 2 $454.20 $682.52 $454.20 EF23-954 2/25/202 3 $200.00 $682.52 $200.00 EF21-5620 12/26/20 21 $200.00 $682.52 $200.00 EF23-156 1/9/2023 $142.06 $682.52 $142.06 EMS2003 8102 9/19/202 0 $2,283.00 $682.52 $682.52 EF22-1200 3/11/202 2 $99.70 $682.52 $99.70 EF22-1675 4/14/202 2 $200.00 $682.52 $200.00 EF22-2874 6/25/202 2 $1,385.19 $682.52 $682.52 SOF20000 00453 1/24/202 0 $1,677.99 $682.52 $682.52 EF23-703 2/10/202 3 $250.00 $682.52 $250.00 EM22- 62250 12/30/20 22 $106.12 $682.52 $106.12 EF22-4556 10/8/202 2 $150.00 $682.52 $150.00 EF23-1434 3/26/202 3 $250.00 $682.52 $250.00 EM21- 37217 9/13/202 1 $2,336.00 $682.52 $682.52 EF23-1587 4/5/2023 $250.00 $682.52 $250.00 EF22-3988 9/1/2022 $100.00 $682.52 $100.00 EMS2002 5340 6/21/202 0 $2,548.00 $682.52 $682.52 EF21-1739 4/16/202 1 $2,357.00 $682.52 $682.52 20004202 1/26/202 0 $1,784.06 $682.52 $682.52 EF21-5152 11/28/20 21 $50.00 $682.52 $50.00 EF22-3654 8/13/202 2 $50.00 $682.52 $50.00 EF22-5526 12/4/202 2 $119.70 $682.52 $119.70 EF22-248 1/14/202 2 $50.00 $682.52 $50.00 EF22-5382 11/27/20 22 $200.00 $682.52 $200.00 EF21-2161 5/15/202 1 $2,230.00 $682.52 $682.52 EF22-1250 3/14/202 2 $110.93 $682.52 $110.93 EF22-4169 9/14/202 2 $106.12 $682.52 $106.12 EF22-653 2/5/2022 $250.00 $682.52 $250.00 EF23-2079 5/3/2023 $200.00 $682.52 $200.00 EF22-5854 12/21/20 22 $250.00 $682.52 $250.00 FF21-2571 5/10/202 1 $671.00 $682.52 $671.00 EF22-5460 11/30/20 22 $118.09 $682.52 $118.09 EF23-206 1/13/202 3 $140.32 $682.52 $140.32 EM21- 23272 6/12/202 1 $2,389.00 $682.52 $682.52 EF23-343 1/21/202 3 $200.00 $682.52 $200.00 EF23-439 1/27/202 3 $250.00 $682.52 $250.00 EF22-633 2/4/2022 $50.00 $682.52 $50.00 EF22-3359 7/24/202 2 $699.60 $682.52 $682.52 EF23-1289 3/17/202 3 $.00 Same $.00 EMS1903 6107 8/9/2019 $2,124.00 $682.52 $682.52 EF23-1588 4/5/2023 $250.00 $682.52 $250.00 EF22-4712 10/17/20 22 $285.00 $682.52 $285.00 EMS2000 4106 1/25/202 0 $2,336.00 $682.52 $682.52 EF22-5605 12/9/202 2 $127.72 $682.52 $127.72 ESF20001 467 3/29/202 0 $2,707.00 $682.52 $682.52 EF22-330 1/18/202 2 $2,382.00 $682.52 $682.52 EF23-465 1/28/202 3 $119.81 $682.52 $119.81 EF22-316 1/17/202 2 $265.00 $682.52 $265.00 EF22-5276 11/19/20 22 $50.00 $682.52 $50.00 EF22-1006 2/27/202 2 $200.00 $682.52 $200.00 EF23-87 1/5/2023 $200.00 $682.52 $200.00 EF21-1369 3/21/202 1 $2,177.00 $682.52 $682.52 EF22-5413 11/28/20 22 $200.00 $682.52 $200.00 EF21-862 2/18/202 1 $2,071.00 $682.52 $682.52 EM21- 19323 5/15/202 1 $2,442.00 $682.52 $682.52 EF22-5910 12/24/20 22 $200.00 $682.52 $200.00 EF22-4780 10/21/20 22 $265.00 $682.52 $265.00 EMS1905 1001 11/7/201 9 $1,563.55 $682.52 $682.52 EF23-842 2/19/202 3 $142.06 $682.52 $142.06 EF21-3783 9/1/2021 $2,283.00 $682.52 $682.52 EF22-2136 5/13/202 2 $389.81 $682.52 $389.81 EMS2002 5864 6/25/202 0 $2,495.00 $682.52 $682.52 EF22-4055 9/6/2022 $1,281.06 $682.52 $682.52 EF22-5393 11/27/20 22 $500.00 $682.52 $500.00 EF22-5760 12/16/20 22 $99.82 $682.52 $99.82 EMS2003 8136 9/19/202 0 $2,463.00 $682.52 $682.52 22015062 39 11/8/202 2 $50.00 $682.52 $50.00 EMS2002 9762 7/23/202 0 $1,542.82 $682.52 $682.52 EF22-5756 12/16/20 22 $500.60 $682.52 $500.60 EF21-3583 8/19/202 1 $274.80 $682.52 $274.80 EMS2001 1138 3/7/2020 $1,113.49 $682.52 $682.52 EF23-851 2/19/202 3 $109.53 $682.52 $109.53 EF22-5282 11/20/20 22 $100.51 $682.52 $100.51 EF22-5021 11/5/202 2 $233.00 $682.52 $233.00 EM23-931 1/6/2023 $227.50 $682.52 $227.50 EF23-2835 6/18/202 3 $100.00 $682.52 $100.00 EF21-3381 8/7/2021 $2,495.00 $682.52 $682.52 EF21-3483 8/13/202 1 $2,230.00 $682.52 $682.52 EF22-1440 3/29/202 2 $75.00 $682.52 $75.00 EF23-829 2/18/202 3 $150.00 $682.52 $150.00 EF23-127 1/8/2023 $200.00 $682.52 $200.00 EF22-5198 11/15/20 22 $150.00 $682.52 $150.00 EF23-932 2/24/202 3 $25.30 $682.52 $25.30 EF21-2110 5/10/202 1 $283.92 $682.52 $283.92 EF21-2204 5/18/202 1 $2,124.00 $682.52 $682.52 EF21-4292 10/4/202 1 $2,328.00 $682.52 $682.52 EF22-4530 10/6/202 2 $200.00 $682.52 200 EF22-56 1/4/2022 $255.00 $682.52 $255.00 EF22-778 2/12/202 2 $150.00 $682.52 $150.00 EF22-337 1/18/202 2 $265.00 $682.52 $265.00 EF22-4156 9/13/202 2 $200.00 $682.52 $200.00 EF22-5417 11/28/20 22 $250.00 $682.52 $250.00 EF22-4235 9/18/202 2 $400.00 $682.52 $400.00 EF23-28 1/2/2023 $227.50 $682.52 $227.50 EF22-954 2/23/202 2 $250.00 $682.52 $250.00 EF23-470 1/28/202 3 $200.00 $682.52 $200.00 EF22-4394 9/28/202 2 $126.11 $682.52 $126.11 EF22-5346 11/24/20 22 $118.09 $682.52 $118.09 EF23-368 1/22/202 3 $250.00 $682.52 $250.00 EF22-700 2/7/2022 $446.40 $682.52 $446.40 EMS1905 9066 12/25/20 19 $1,380.88 $682.52 $682.52 22-3596 8/9/2022 $803.00 $682.52 $682.52 EF22-1878 4/27/202 2 $2,328.00 $682.52 $682.52 EF22-5201 11/15/20 22 $100.00 $682.52 $100.00 EMS2004 3338 10/24/20 20 $1,580.03 $682.52 $682.52 FF22-5707 10/14/20 22 $768.00 $682.52 $682.52 EF22-5537 12/5/202 2 $250.00 $682.52 $250.00 EM21- 21027 5/27/202 1 $300.00 $682.52 $300.00 EF22-480 1/26/202 2 $100.00 $682.52 $100.00 EF22-2933 6/28/202 2 $265.00 $682.52 $265.00 EF21-5536 12/21/20 21 $250.00 $682.52 $250.00 EMS2004 7162 11/19/20 20 $2,283.00 $682.52 $682.52 EF23-960 2/25/202 3 $699.60 $682.52 $682.52 EF21-5366 12/10/20 21 $200.00 $682.52 $200.00 EF21-4349 10/8/202 1 $250.00 $682.52 $250.00 EF22-3448 8/1/2022 $626.40 $682.52 $626.40 EMS2002 9553 7/22/202 0 $50.00 $682.52 $50.00 EF22-4715 10/18/20 22 $100.00 $682.52 $100.00 EF23-694 2/9/2023 $227.50 $682.52 $227.50 EMS2100 4087 1/26/202 1 $2,389.00 $682.52 $682.52 EF22-1206 3/11/202 2 $265.00 $682.52 $265.00 EMS2000 2753 1/17/202 0 $2,442.00 $682.52 $682.52 EF23-259 1/16/202 3 $138.58 $682.52 $138.58 EF21-4136 9/25/202 1 $393.13 $682.52 $393.13 EF21-3754 8/30/202 1 $417.13 $682.52 $417.13 EF21-2818 6/29/202 1 $2,442.00 $682.52 $682.52 EF22-4044 9/5/2022 $748.56 $682.52 $682.52 EF22-124 1/7/2022 $150.00 $682.52 $150.00 EMS2005 1263 12/15/20 20 $32.00 $682.52 $32.00 EF23-991 2/27/202 3 $150.00 $682.52 $150.00 EF23-1779 4/16/202 3 $75.00 $682.52 $75.00 EMS2004 2096 10/15/20 20 $1,673.68 $682.52 $682.52 EMS1901 0427 3/5/2019 $2,068.00 $682.52 $682.52 EF21-5101 11/25/20 21 $2,436.00 $682.52 $682.53 EF22-5456 11/30/20 22 $200.00 $682.52 $200.00 EF22-2352 5/25/202 2 $2,291.74 $682.52 $682.52 EF23-307 1/19/202 3 $50.00 $682.52 $50.00 EM22- 60834 12/22/20 22 $200.00 $682.52 $200.00 EF22-2669 6/11/202 2 $250.00 $682.52 $250.00 EF22-5305 11/21/20 22 $707.80 $682.52 $682.52 EF21-5486 12/18/20 21 $150.00 $682.52 $150.00 EF23-1633 4/6/2023 $135.44 $682.52 $135.44 EMS1904 4204 9/27/201 9 $1,563.51 $682.52 $682.52 EF22-953 2/23/202 2 $2,317.60 $682.52 $682.52 EF23-1127 3/8/2023 $150.00 $682.52 $150.00 EF23-528 1/31/202 3 $200.00 $682.52 $200.00 EF23-647 2/7/2023 $200.00 $682.52 $200.00 EF22-5260 11/19/20 22 $265.00 $682.52 $265.00 EF22-4939 10/31/20 22 $200.00 $682.52 $200.00 EMS1803 7144 8/20/201 8 $2,256.00 $682.52 $682.52 EF22-679 2/6/2022 $207.39 $682.52 $207.39 EF22-4782 10/21/20 22 $200.00 $682.52 $200.00 EF22-912 2/21/202 2 $265.00 $682.52 $265.00 EM22- 53199 11/11/20 22 $2,332.00 $682.52 $682.52 EF21-1855 4/24/202 1 $2,283.00 $682.52 $682.52 EF22-2113 5/12/202 2 $126.11 $682.52 $126.11 EF22-4452 10/2/202 2 $250.30 $682.52 $250.30 EF21-2502 6/8/2021 $2,177.00 $682.52 $682.52 EF23-1213 3/12/202 3 $200.00 $682.52 $200.00 EF23-762 2/14/202 3 $131.61 $682.52 $131.61 EMS2100 0816 1/6/2021 $2,516.00 $682.52 $682.52 20016823 4/16/202 0 $1,694.25 $682.52 $682.52 EF23-145 1/9/2023 $200.00 $682.52 $200.00 EMS1800 3023 1/18/201 8 $2,050.00 $682.52 $682.52 EMS1903 7729 8/18/201 9 $1,145.78 $682.52 $682.52 EF21-4082 9/21/202 1 $300.00 $682.52 $300.00 EMS2004 1440 10/11/20 20 $2,071.00 $682.52 $682.52 EF22-1560 4/6/2022 $243.00 $682.52 $243.00 EF22-170 1/9/2022 $150.00 $682.52 $150.00 EF22-2129 5/13/202 2 $200.00 $682.52 $200.00 EMS2003 3670 8/19/202 0 $2,230.00 $682.52 $682.52 EF21-2950 7/8/2021 $2,283.00 $682.52 $682.52 EF22-4455 10/2/202 2 $1,316.40 $682.52 $682.52 EF22-3926 8/29/202 2 $2,130.00 $682.52 $682.52 EF22-2782 6/19/202 2 $633.60 $682.52 $633.60 EMS2003 7613 9/16/202 0 $1,959.63 $682.52 $682.52 EF23-203 1/13/202 3 $200.00 $682.52 $200.00 EF22-5656 12/11/20 22 $200.00 $682.52 $200.00 EF23-476 1/28/202 3 $112.84 $682.52 $112.84 EMS2005 1294 12/15/20 20 $2,283.00 $682.52 $682.52 EF23-262 1/16/202 3 $200.00 $682.52 $200.00 EF22-3731 8/18/202 2 $250.00 $682.52 $250.00 EF22-62 1/4/2022 $75.00 $682.52 $75.00 EMS1900 3116 1/19/201 9 $1,286.90 $682.52 $682.52 EMS1900 0564 1/4/2019 $1,736.45 $682.52 $682.52 EF22-1384 3/24/202 2 $200.00 $682.52 $200.00 EMS1903 1800 7/12/201 9 $1,360.51 $682.52 $682.52 EMS1904 9119 10/27/20 19 $2,259.93 $682.52 $682.52 EF23-1377 3/22/202 3 $150.00 $682.52 $150.00 EF22-670 2/6/2022 $200.00 $682.52 $200.00 EF22-5662 12/12/20 22 $200.00 $682.52 $200.00 EF22-4862 10/26/20 22 $265.00 $682.52 $265.00 EMS1901 0876 3/7/2019 $1,754.23 $682.52 $682.52 EMS1904 6788 10/12/20 19 $2,389.00 $682.52 $682.53 EF22-4208 9/16/202 2 $250.00 $682.52 $250.00 EF23-61 1/4/2023 $250.00 $682.52 $250.00 EF22-5695 12/14/20 22 $99.70 $682.52 $99.70 EF22-5902 12/23/20 22 $265.00 $682.52 $265.00 EF21-4114 9/23/202 1 $2,436.00 $682.52 $682.52 EF23-1959 4/26/202 3 $200.00 $682.52 $200.00 EF22-1196 3/11/202 2 $376.80 $682.52 $376.80 EF21-5604 12/25/20 21 $250.00 $682.52 $250.00 EF22-4551 10/8/202 2 $30.00 $682.52 $30.00 EF21-4887 11/11/20 21 $150.00 $682.52 $150.00 EF23-2108 5/4/2023 $50.00 $682.52 $50.00 EF22-5754 12/16/20 22 $50.00 $682.52 $50.00 EF21-4998 11/19/20 21 $100.00 $682.52 $100.00 EF22-4313 9/23/202 2 $50.00 $682.52 $50.00 EF21-4666 10/27/20 21 $150.00 $682.52 $150.00 EF23-551 2/1/2023 $200.00 $682.52 $200.00 EF23-836 2/19/202 3 $50.00 $682.52 $50.00 ESF17003 181 8/4/2017 $2,250.00 $682.52 $682.52 EF23-944 2/25/202 3 $200.00 $682.52 $200.00 EF22-5298 11/21/20 22 $246.90 $682.52 $246.90 EF22-2428 5/29/202 2 $666.00 $682.52 $666.00 EF22-648 2/5/2022 $50.00 $682.52 $50.00 EF23-1161 3/9/2023 $75.00 $682.52 $75.00 EMS1905 0309 11/3/201 9 $1,291.44 $682.52 $682.52 EMS2100 3983 1/26/202 1 $2,389.00 $682.52 $682.52 EMS2004 6218 11/13/20 20 $2,124.00 $682.52 $682.52 EF21-5521 12/21/20 21 $250.00 $682.52 $250.00 EF23-1080 3/5/2023 $50.00 $682.52 $50.00 EF22-671 2/6/2022 $122.91 $682.52 $122.91 EF22-4247 9/19/202 2 $250.00 $682.52 $250.00 EF22-4193 9/15/202 2 $200.00 $682.52 $200.00 EF21-5236 12/3/202 1 $200.00 $682.52 $200.00 EF23-674 2/8/2023 $292.77 $682.52 $292.77 EF23-1182 3/10/202 3 $50.00 $682.52 $50.00 EF22-5485 12/2/202 2 $200.00 $682.52 $200.00 EF23-1275 3/16/202 3 $200.00 $682.52 $200.00 EF22-5157 11/13/20 22 $127.72 $682.52 $127.72 EF23-352 1/21/202 3 $200.00 $682.52 $200.00 EF22-2670 6/11/202 2 $733.00 $682.52 $682.52 EMS2003 1564 8/6/2020 $2,177.00 $682.52 $682.52 EF21-1912 4/27/202 1 $2,177.00 $682.52 $682.52 EF23-1382 3/22/202 3 $150.00 $682.52 $150.00 EF21-2895 7/5/2021 $100.00 $682.52 $100.00 EF22-252 1/15/202 2 $250.00 $682.52 $250.00 EF22-2851 6/23/202 2 $265.00 $682.52 $265.00 EF22-1087 3/3/2022 $127.40 $682.52 $127.40 EMS1901 7755 4/19/201 9 $1,130.41 $682.52 $682.52 EF22-273 1/15/202 2 $2,112.00 $682.52 $682.52 EM23- 7726 2/14/202 3 $250.00 $682.52 $250.00 EMS1805 0030 11/8/201 8 $2,511.00 $682.52 $682.52 EF22-3193 7/12/202 2 $265.00 $682.52 $265.00 EMS2000 7041 2/11/202 0 $1,688.90 $682.52 $682.52 EF23-217 1/14/202 3 $200.00 $682.52 $200.00 EF22-375 1/20/202 2 $50.00 $682.52 $50.00 EF23-1386 3/23/202 3 $150.00 $682.52 $150.00 EM23- 22637 5/9/2023 $50.00 $682.52 $50.00 EF22-162 1/9/2022 $111.83 $682.52 $111.83 EF22-329 1/18/202 2 $455.60 $682.52 $455.60 EF22-4453 10/2/202 2 $699.60 $682.52 $682.52 EF23-1089 3/6/2023 $150.00 $682.52 $150.00 EF23-2124 5/5/2023 $121.55 $682.52 $121.55 EF21-5693 12/30/20 21 $347.13 $682.52 $347.13 EF22-4720 10/18/20 22 $100.00 $682.52 $100.00 EF23-1154 3/9/2023 $200.00 $682.52 $200.00 EF22-5596 12/8/202 2 $250.00 $682.52 $250.00 EF23-187 1/12/202 3 $100.00 $682.52 $100.00 EF22-868 2/17/202 2 $100.00 $682.52 $100.00 EMS1905 9103 12/26/20 19 $2,177.00 $682.52 $682.52 EF22-5592 12/8/202 2 $98.10 $682.52 $98.10 EMS2003 4628 8/26/202 0 $2,601.00 $682.52 $682.52 EF22-2617 6/9/2022 $311.10 $682.52 $1,630.00 EMS2004 2155 10/16/20 20 $1,630.00 $682.52 $682.52 EM22- 24703 6/1/2022 $698.40 $682.52 $682.52 EF22-3541 8/7/2022 $100.00 $682.52 $100.00 EF22-299 1/17/202 2 $114.14 $682.52 $114.14 EF22-549 1/30/202 2 $200.00 $682.52 $200.00 EF22-5090 11/9/202 2 $300.00 $682.52 $300.00 EF22-1372 3/23/202 2 $2,544.00 $682.52 $682.52 EF22-5037 11/6/202 2 $128.84 $682.52 $128.84 EF23-2061 5/2/2023 $50.00 $682.52 $50.00 EF23-367 1/22/202 3 $250.00 $682.52 $250.00 EF22-4657 10/15/20 22 $50.00 $682.52 $50.00 EF22-3556 8/8/2022 $2,389.00 $682.52 $682.52 EF22-3377 7/25/202 2 $101.31 $682.52 $101.31 EF22-1864 4/26/202 2 $121.30 $682.52 $121.30 EF22-1256 3/15/202 2 $75.00 $682.52 $75.00 EF22-5777 12/17/20 22 $50.00 $682.52 $50.00 EF21-4029 9/17/202 1 $16.00 $682.52 $16.00 EMS2003 5798 9/4/2020 $2,071.00 $682.52 $682.52 FF22-6396 11/16/20 22 $233.18 $682.52 $233.18 EF22-1510 4/3/2022 $243.00 $682.52 $243.00 EF22-3750 8/19/202 2 $2,361.70 $682.52 $682.52 EM22- 62455 12/31/20 22 $265.00 $682.52 $265.00 EF22-3543 8/7/2022 $50.00 $682.52 $50.00 EF22-722 2/9/2022 $384.00 $682.52 $384.00 EF23-1598 4/5/2023 $943.90 $682.52 $682.52 EF23-1748 4/14/202 3 $200.00 $682.52 $200.00 EMS1905 5651 12/6/201 9 $3,343.00 $682.52 $682.52 EF22-1495 4/1/2022 $2,274.00 $682.52 $682.52 EF22-5197 11/15/20 22 $150.00 $682.52 $150.00 EF22-96 1/6/2022 $50.00 $682.52 $50.00 EF22-1413 3/26/202 2 $200.00 $682.52 $200.00 EF23-1001 2/28/202 3 $200.00 $682.52 $200.00 EMS2002 6720 7/1/2020 $1,634.39 $682.52 $682.52 EF22-5348 11/24/20 22 $100.00 $682.52 $100.00 EF22-3699 8/16/202 2 $250.00 $682.52 $250.00 EF23-1715 4/11/202 3 $50.00 $682.52 $50.00 EF22-3209 7/13/202 2 $45.00 $682.52 $45.00 EF23-2007 4/28/202 3 $50.00 $682.52 $50.00 EMS2003 3515 8/18/202 0 $1,136.00 $682.52 $682.52 EF21-5123 11/26/20 21 $524.80 $682.52 $524.80 EF23-1791 4/17/202 3 $250.00 $682.52 $250.00 EF23-1622 4/6/2023 $250.00 $682.52 $250.00 EF23-625 2/6/2023 $150.00 $682.52 $150.00 EF23-529 1/31/202 3 $200.00 $682.52 $200.00 EF21-2571 6/13/202 1 $2,442.00 $682.52 $682.52 EMS2004 1939 10/14/20 20 $2,283.00 $682.52 $682.52 EF23-1635 4/7/2023 $250.00 $682.52 $250.00 EF22-5742 12/16/20 22 $185.00 $682.52 $185.00 EMS2000 8043 2/17/202 0 $1,613.83 $682.52 $682.52 EMS1911 115 3/9/2019 $1,522.00 $682.52 $682.52 EF23-884 2/21/202 3 $135.10 $682.52 $135.10 EMS2002 7743 7/9/2020 $1,712.96 $682.52 $682.52 EF22-1225 3/12/202 2 $2,166.00 $682.52 $682.52 EF23-355 1/22/202 3 $100.00 $682.52 $100.00 EF22-4098 9/8/2022 $50.00 $682.52 $50.00 EF21-1121 3/7/2021 $872.38 $682.52 $682.52 EF23-1132 3/8/2023 $256.00 $682.52 $256.00 EF23-1653 4/8/2023 $200.00 $682.52 $200.00 EF22-348 1/19/202 2 $150.00 $682.52 $150.00 EMS2004 3613 10/26/20 20 $2,442.00 $682.52 $682.52 EF21-2308 5/26/202 1 $2,177.00 $682.52 $682.52 EMS1904 6290 10/10/20 19 $1,875.58 $682.52 $682.52 EF22-656 2/5/2022 $200.00 $682.52 $200.00 EF23-1277 3/16/202 3 $50.00 $682.52 $50.00 EF22-4447 10/1/202 2 $200.00 $682.52 $200.00 EF22-4846 10/25/20 22 $100.00 $682.52 $100.00 EF23-209 1/13/202 3 $133.70 $682.52 $133.70 EF22-4046 9/5/2022 $150.00 $682.52 $150.00 EF21-1371 3/21/202 1 $2,972.00 $682.52 $682.52 EMS2003 2843 8/15/202 0 $1,105.60 $682.52 $682.52 EF22-685 2/6/2022 $200.00 $682.52 $200.00 EF23-2573 6/3/2023 $142.06 $682.52 $142.06 EMS2000 9191 2/24/202 0 $1,773.19 $682.52 $682.52 EF22-4605 10/12/20 22 $50.00 $682.52 $50.00 EF22-3934 8/29/202 2 $250.00 $682.52 $250.00 EF22-3613 8/11/202 2 $699.60 $682.52 $682.52 EF23-424 1/26/202 3 $745.50 $682.52 $682.52 EF22-391 1/21/202 2 $931.20 $682.52 $682.52 EF23-763 2/14/202 3 $302.35 $682.52 $302.35 EMS1803 7114 8/20/201 8 $1,515.59 $682.52 $682.52 EF22-3888 8/26/202 2 $235.00 $682.52 $235.00 EF22-3519 8/5/2022 $250.00 $682.52 $250.00 EF23-445 1/27/202 3 $123.30 $682.52 $123.30 EF22-102 1/6/2022 $50.00 $682.52 $50.00 EMS2005 3564 12/30/20 20 $2,177.00 $682.52 $682.52 EF22-4716 10/18/20 22 $165.00 $682.52 $165.00 EF21-3728 8/28/202 1 $2,283.00 $682.52 $682.52 EF22-4029 9/4/2022 $200.00 $682.52 $200.00 EF23-805 2/17/202 3 $200.00 $682.52 $200.00 EF22-1343 3/21/202 2 $186.80 $682.52 $186.80 EF22-5953 12/26/20 22 $50.00 $682.52 $50.00 EMS1905 7971 12/19/20 19 $2,442.00 $682.52 $682.52 EMS2002 9482 7/21/202 0 $1,673.68 $682.52 $682.52 EF22-3984 9/1/2022 $731.00 $682.52 $682.52 EF22-1498 4/2/2022 $200.00 $682.52 $200.00 EF21-3126 7/21/202 1 $2,463.00 $682.52 $682.52 18026472 6/12/201 8 $2,400.00 $682.52 $682.52 EF21-2542 6/11/202 1 $2,336.00 $682.52 $682.52 EF22-4878 10/27/20 22 $50.00 $682.52 $50.00 EMS1904 4417 9/28/201 9 $1,436.51 $682.52 $682.52 EMS1902 1538 5/12/201 9 $2,307.00 $682.52 $682.52 EF23-761 2/14/202 3 $50.00 $682.52 $50.00 EMS1905 8450 12/22/20 19 $1,531.00 $682.52 $682.52 EMS1805 6629 12/18/20 18 $2,409.00 $682.52 $682.52 EMS2001 8900 5/3/2020 $1,119.52 $682.52 $682.52 EF22-780 2/12/202 2 $200.00 $682.52 $200.00 EF22-3637 8/12/202 2 $110.93 $682.52 $110.93 EF22-1533 4/4/2022 $200.00 $682.52 $200.00 EF22-5735 12/15/20 22 $50.00 $682.52 $50.00 EF21-4781 11/4/202 1 $250.00 $682.52 $250.00 EMS1902 1895 5/14/201 9 $2,409.00 $682.52 $682.52 EF23-1104 3/6/2023 $200.00 $682.52 $200.00 EF22-3598 8/9/2022 $1,549.79 $682.52 $682.52 EF23-588 2/3/2023 $50.00 $682.52 $50.00 EF23-341 1/21/202 3 $200.00 $682.52 $200.00 EF22-1473 3/31/202 2 $200.00 $682.52 $200.00 EF22-1268 3/16/202 2 $69.27 $682.52 $69.27 FF22-1270 3/2/2022 $200.00 $682.52 $200.00 EF22-5784 12/18/20 22 $250.00 $682.52 $250.00 EF22-37 1/3/2022 $2,490.00 $682.52 $682.52 EF22-4505 10/5/202 2 $50.00 $682.52 $50.00 EF23-605 2/4/2023 $50.00 $682.52 $50.00 EF22-2266 5/20/202 2 $2,328.00 $682.52 $682.52 EMS1904 8665 10/24/20 19 $2,516.00 $682.52 $682.52 EF23-1860 4/21/202 3 $50.00 $682.52 $50.00 EF22-1447 3/29/202 2 $200.00 $682.52 $200.00 EMS1904 2749 9/18/201 9 $1,999.28 $682.52 $682.52 EF22-848 2/16/202 2 $119.86 $682.52 $119.86 EF22-3669 8/14/202 2 $125.15 $682.52 $125.15 EF22-433 1/23/202 2 $2,112.00 $682.52 $682.52 EF22-2334 5/24/202 2 $1,634.98 $682.52 $682.52 EF22-1436 3/29/202 2 $270.60 $682.52 $270.60 EF21-5694 12/30/20 21 $444.00 $682.52 $444.00 EF22-2451 5/30/202 2 $109.33 $682.52 $109.33 EF22-4494 10/4/202 2 $100.00 $682.52 $100.00 FF22-4178 7/29/202 2 $200.00 $682.52 $200.00 EF22-4987 11/3/202 2 $75.00 $682.52 $75.00 EMS2002 8708 7/16/202 0 $1,669.82 $682.52 $682.52 EF21-2144 5/13/202 1 $100.00 $682.52 $100.00 EF23-1989 4/27/202 3 $250.00 $682.52 $250.00 EMS2003 4537 8/25/202 0 $1,673.68 $682.52 $682.52 EF22-5626 12/10/20 22 $175.00 $682.52 $175.00 EF22-4839 10/24/20 22 $121.30 $682.52 $121.30 EF22-4897 10/29/20 22 $100.00 $682.52 $100.00 EF21-2172 5/15/202 1 $2,389.00 $682.52 $682.52 EF22-3959 8/30/202 2 $250.00 $682.52 $250.00 EF22-4814 10/23/20 22 $2,275.00 $682.52 $682.52 EF22-5763 12/16/20 22 $1,187.16 $682.52 $682.52 EF22-5343 11/24/20 22 $466.40 $682.52 $466.40 EF22-5337 11/23/20 22 $150.00 $682.52 $150.00 EF22-4092 9/8/2022 $307.70 $682.52 $307.70 EF22-4410 9/29/202 2 $109.33 $682.52 $109.33 EF23-212 1/13/202 3 $200.00 $682.52 $200.00 EF22-5528 12/4/202 2 $127.72 $682.52 $127.72 EMS1804 9865 11/7/201 8 $2,052.00 $682.52 $682.52 EF22-456 1/25/202 2 $265.00 $682.52 $265.00 EM22- 57133 12/2/202 2 $50.00 $682.52 $50.00 EF21-5042 11/22/20 21 $200.00 $682.52 $200.00 EF22-4428 9/30/202 2 $265.00 $682.52 $265.00 Formula Adjusted Amount EMS1801 7016 4/13/2018 $2,600.00 $682.52 $682.52 EMS1805 3279 11/28/2018 $2,052.00 $682.52 $682.53 EMS1901 0047 3/2/2019 $2,409.00 $682.52 $682.54 EMS1901 8207 4/22/2019 $250.00 $682.52 $250.00 EMS1901 8637 4/25/2019 $250.00 $682.52 $250.00 EMS1901 9420 4/29/2019 $250.00 $682.52 $250.00 EMS1931 093 7/8/2019 $200.00 $682.52 $200.00 EMS2000 8011 2/17/2020 $200.00 $682.52 $200.00 EMS1902 6303 6/9/2019 $2,205.00 $682.52 $682.52 EMS1904 1515 9/11/2019 $2,177.00 $682.52 $682.52 EMS1905 6769 12/12/2019 $2,336.00 $682.52 $682.52 EMS2000 0981 1/7/2020 $2,074.00 $682.52 $682.52 EMS2000 1767 1/12/2020 $2,336.00 $682.52 $682.52 EMS2000 2938 1/18/2020 $2,124.00 $682.52 $682.52 EMS2001 0880 3/5/2020 $2,283.00 $682.52 $682.52 EMS2001 2860 3/18/2020 $2,236.00 $682.52 $682.52 EMS2001 7900 4/25/2020 $2,124.00 $682.52 $682.52 EMS2002 2045 5/28/2020 $2,283.00 $682.52 $682.52 EMS2003 4452 8/25/2020 $1,827.16 $682.52 $682.52 EMS2003 8306 9/21/2020 $2,389.00 $682.52 $682.52 EMS2004 1351 10/11/2020 $2,071.00 $682.52 $682.52 EMS2005 2577 12/23/2020 $2,304.00 $682.52 $682.52 EF21-871 2/18/2021 $477.80 $682.52 $477.80 EF21-1278 3/16/2021 $2,336.00 $682.52 $682.52 EF21-1433 3/25/2021 $2,251.00 $682.52 $682.52 EF21-1942 4/29/2021 $2,016.08 $682.52 $682.52 EF21-4363 10/9/2021 $2,112.00 $682.52 $682.52 EF21-4400 10/11/2021 $2,112.00 $682.52 $682.52 EF21-4655 10/27/2021 $2,382.00 2382 $2,382.00 $267,493.60 Administrative Instruction Section IV No. 9 Financial Hardship Policy Effective Date: February 1, 2024 ______________________________________________________________________________ Purpose The City of South San Francisco finds that, although there may be incidental benefits to private individuals, the public purpose of relieving those most in need of financial relief of the typically unexpected financial hardship of ambulance transport and copayment charges serves a compelling public interest in ensuring that individuals are able to receive necessary medical treatment, among other public benefits. This Administrative Instruction establishes a policy in order to maintain consistency in assisting uninsured and indigent patients who request a reduction or waiver of certain ambulance charges and/or copayment amounts. This policy outlines the City’s policies and procedures in relation to the application and approval process for uninsured and indigent patients. The City will take into account the overall financial circumstances of the applicant and apply this policy consistently. The City may elect to reduce or waive certain amounts which are due from patients who can successfully demonstrate that paying ambulance charges and/or copayment amounts would cause significant financial hardship. This policy has been updated to reflect the amendments made to California law under Assembly Bill 716 (2023), and legally allowable collection activities. Though the City does not presently have a formal collection process beyond third-party insurance identification, these practices will be followed, consistent with the law, should the City engage a debt collection agency. Accordingly, the City has a 12-month abeyance on the collection of any medical debt, as required by law. Policy The City of South San Francisco will take into account a range of factors when deciding whether Administrative Instruction – Financial Hardship Policy Section IV No. 9 (Page 2) 08/01/2016 C:\Users\vacevedo\AppData\Roaming\L5\Temp\21a98216-7f0b-4622-b32c-60f21f7910eb.doc the full payment of the ambulance charges will cause the applicant significant financial hardship. In making the decision whether to waive the charges, the City will compare the household income, living expenses, assets and debts. Written verification, when available, may be required to substantiate and verify information contained in the financial hardship waiver application. Any amount not paid by a patient’s insurance provider (if any) shall be adjusted to the prevailing Medicare or Medi-Cal fee for service rate, whichever is greater, prior to formal collections proceedings. Currently, the City does not recognize “network” rates for any providers other than those required by law. The City’s ambulance fee schedule is set by the South San Francisco City Council, guided by cost and fee studies, and is published on the City’s website. The City uses the most recent County of San Mateo Department of Housing Income Limits by Family size to help in determining if an applicant qualifies for a financial hardship waiver. In applying these guidelines, the City will also consider and take into account any other household income and expenses. Income and employment status verification are required; including tax returns; check stubs, etc. Other considerations include: 1. Whether payment of the ambulance or copayment charges will affect the applicant’s ability to pay for the following living expenses: • food and clothes; • rent or mortgage payments; • any other basic needs; or • any special needs (for a serious illness or disability) 2. Whether the applicant owns any assets, such as a car and/or house. Assets also include: • investments; • money in the bank; • cash on hand for short term expenses; and • money designated for special needs. 3. Whether the applicant has any debts. Procedures An application for a financial hardship waiver of ambulance or copayment charges and fees must be made in accordance with City of South San Francisco’s, (hereinafter referred to as City), policy entitled “Financial Hardship”. Applicants can request and complete a Financial Hardship Waiver Application Form. The form can be obtained by calling (650) 829-3950 or by visiting the South San Francisco Fire Department Administrative Instruction – Financial Hardship Policy Section IV No. 9 (Page 3) 08/01/2016 C:\Users\vacevedo\AppData\Roaming\L5\Temp\21a98216-7f0b-4622-b32c-60f21f7910eb.doc Administration office at 480 North Canal Street, South San Francisco, CA 94080, during normal business hours. Forms can also be requested, through submission of a written request, to the above listed address for the Fire Department Administration Offices and are downloadable online at http://www.ssf.net/432/EMS---ALS. If applying in person, please be prepared to offer written verification of the necessary information about your financial circumstances. If you have difficulty performing any of these tasks, please contact the Fire Department at (650) 829-3950. Applicants are required to return the completed forms and submit all required documentation to the South San Francisco Fire Department located at 480 North Canal Street, South San Francisco, CA 94080. An application may also be submitted electronically by requesting a username from the City’s secured site. Please submit your request to
[email protected]
for access to the site. In order to protect your personal information, please do not e-mail your financial hardship waiver application to this address until you have received access to our secured site. Required Information: The City requires independent information to support claims of financial hardship, including verification of expenses and income. The information submitted will be treated confidentially and will only be reviewed by City administrative staff involved in processing requests for a waiver of ambulance and copayment charges. Time Frame: After an application and verification information is received, the City will consider the overall financial situation of the applicant and then render a decision. The City has designated the authority to grant or reject requests for financial hardship waivers to the City’s Director of Finance. All decisions will be made within 20 business days from the time that the City receives all required information. Applicants will receive a notification letter stating whether the application has been approved or rejected. If your request for waiver of the charges is rejected, the City will provide the applicant with a written summary and explanation of its decision. The Fire Department administrative staff will maintain all documentation related to the financial hardship waiver process. This documentation will include all supporting documentation, including the waiver request and all documents provided in support of the request. Verification of ongoing qualification for a financial hardship waiver will be conducted at any time the applicant requests a waiver of ambulance charges or other applicable copayment amounts. Administrative Instruction – Financial Hardship Policy Section IV No. 9 (Page 4) 08/01/2016 C:\Users\vacevedo\AppData\Roaming\L5\Temp\21a98216-7f0b-4622-b32c-60f21f7910eb.doc Income shall be annualized from the date of request based on documentation provided, and upon verbal information provided by the patient or their designee. The annualization process will also take into consideration seasonal employment and temporary increases and/or decreases to income. Any denial of a financial hardship waiver request will be written and will include instructions for possible reconsideration. If additional documentation of financial need is received, the request will be reviewed and considered per the above guidelines. Sharon Ranals City Manager Dated: