Application For Financial Assistance

Application For Financial Assistance
APPLICANT INFORMATION
Applicant's First & Last Name *

First Name Last Name
Applicant's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
Email Address
example@example.com
Confirm Email Address
example@example.com
Relationship to the cancer patient that financial support is being applied for?
CANCER PATIENT INFORMATION

(If not the person applying)
Patient's First Name *
Patient's Last Name *
Patient's Date of Birth *

Month Day Year
Gender
Ethnicity
Marital Status
Religion
Language
Place of Birth
HEALTH INSURANCE INFORMATION
Does the patient have health insurance? *

Yes No
If yes, please note the type of insurance (select all that apply):

Private Insurance Medicaid Medicare Medicare Plus Medigap Veteran's Administration Benefits Other (if "Other" please specify below)
FINANCIAL ASSISTANCE NEEDS
I need financial assistance to offset the following cancer-related expenses: (check all that apply)

Basic Living Expenses (Mortgage/Rent/Utilities/Food) Transportation Home Care (Nursing Services & Cleaning) Pain Medications Lymphedema Supplies Child Care Personal Items (Wig Services, Prosthesis Bras, Hats) Other (If "Other", please specify below)
FINANCIAL INFORMATION
Is the patient employed?

Yes No
Number of people in the household:
Please list members of the household (including age/relationship to patient)
Household Income (check all that apply):

Salary Public Assistance Pension Short Term Disability Social Security (Retirement) Unemployment Social Security Disability Family/Friends Provide Support SSI Other (If "Other", please specify below)
Total Annual Family Income *
FAMILY ASSETS

Please include info from all household members
Checking/Money Market Accounts:
Savings/CD:
IRA/403B/401K:
Stock & Bonds:
Other:
Total Family Assets:
Please upload a copy of a letter from your medical provider verifying your current breast cancer treatment. Providing this information with the submission of your application will assist in expediting the processing of your application. *

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Information will be reviewed by The Donna M. Saunders Foundation and we will contact the applicant. All information is confidential and for use by The Donna M. Saunders Foundation only.
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Application For Financial Assistance

APPLICANT INFORMATION

CANCER PATIENT INFORMATION

HEALTH INSURANCE INFORMATION

FINANCIAL ASSISTANCE NEEDS

FINANCIAL INFORMATION

FAMILY ASSETS