(Fill your name in if you receive this); I am a little light in the attic so I don't really know how to ask for what I am seeking. Application for financial assistance to Nassau County lndustrial Development Agency for site improvements and replacements-in-kind at existing.Your letter should clearly state the facts of your family's financial situation and your financial need. This application can be used to apply for Medicaid, the. Family Planning Benefit Program, or for assistance paying your health insurance premiums. We provide care without regard to source of payment. If you do not have insurance or another way to pay, please call our Financial Assistance counselors. One signed original and one photocopy of the Application (including all attachments) must be submitted. Bring sample documentation as noted below to confirm property ownership and income. Each applicant must provide a signed application and W-9 form.