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Unique Just Heart Case ID
Application Status
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Approved
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Application Status Approve/Disapprove Date
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Month
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Day
Year
Date
Case Status
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Open
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TOTAL MONTHLY INCOME
TOTAL MONTHLY EXPENSES
TOTAL ASSETS
TOTAL DEBTS
Notes
Welcome!
Thank you for considering Just Heart Foundation for support during this challenging time. As a small nonprofit, our application process is highly selective, and while we aim to assist as many families as possible, we cannot guarantee approval for every application. To be considered, please complete your application thoroughly and provide detailed information about your financial situation before and after your child’s medical crisis, as well as any plans for regaining stability.If approved, we invite you to pledge support for future families by raising funds through a personalized fundraiser link we provide or other means. This voluntary effort helps sustain our mission to assist families in need.We appreciate your understanding and cooperation.Should you have any questions, you may email us at contact@justheart.org
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Your Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Number
*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Other Phone
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Email
*
example@example.com
Date of Birth
*
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Month
 -
Day
Year
Date
Gender / Sex
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Male
Female
N/A
Resident Status
*
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US Citizen
Lawful Permanent Resident
Race
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White
Native American or Alaska Native
Asian
Asian Indian
Black or African American
Native Hawaiian or Other
Hispanic or Latino
Marital Status
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Married
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Single
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Military Status
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N/A
Active Duty
Reserves
Retired
Last 4 Digits of SS#
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Co-Applicants
Co-Applicant 1
Co-Applicant 2
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Housing
Housing Status
*
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Owner
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Number of Adults in Household
*
Number of Children in Household
*
Number of Dependents Under 18 in Household
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Number of Dependents Over 18 in Household
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Number of Non-Dependents in Household
*
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Family
Number of Parents
*
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1 Parent
2 Parents
Number of Children
*
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Child’s Medical Condition
*
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Heart
Autism
Transplant
Cancer
NICU
Accident
Other
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Employment
Employment Status
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Employed Full-Time
Employed Part-Time
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Employer 1
Employer 2
Employer 3
Previous Employer
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Finances
Monthly Household Income Information
Salary / Wages
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Alimony / Child Support
Rental Income
Self-Employment Income
Pension
Retirement
Social Security Disability
Social Security Income
Unemployment
Other Income
Monthly Household Living Expense Information
Monthly Mortgage / Rent
*
Utilities (Total of Power / Gas / Water / Trash)
*
Phone
Cable / Satellite / Internet
Insurance
Child Care Expenses
Car Payments
Child Support / Alimony
Other Living Expenses
Household Asset Information
Current Checking Account Balance
*
Current Savings Account Balance
*
Value of Automobiles
Home Value
Household Liability and Debt Information
Mortgage Loan Balance
Auto Loan Balance
Student Loan Balance
Credit Card Loan(s) Balance
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Additional Information
Social Worker
*
First Name
Last Name
Social Worker Email
*
example@example.com
Social Worker Phone Number
*
Please enter a valid phone number.
Primary Pediatrician
First Name
Last Name
Name of Practice
Pediatrician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pediatrician Phone Number
Please enter a valid phone number.
Institution Name
Please Select
Children's Healthcare of Atlanta
Children's Hospital of Alabama
Children's at Erlanger
Sibley Heart Center
Marcus Autism Center
Other
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Do you have Medical Insurance?
*
Please Select
Yes
No
Insurance Company
Are you receiving assistance from any other organization?
*
Please Select
Yes
No
If yes, please provide details
Have you ever filed bankruptcy?
*
Please Select
Yes
No
If yes, please provide details
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Our Story
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Family or Child Photo:
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Were you self-sufficient before your medical crisis?
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Will a grant of this kind return you to self-sufficiency?
*
Please briefly describe how.
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How will you maintain this self-sufficiency once the grant has expired?
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