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Unique Just Heart Case ID
Application Status
Please Select
Approved
Denied
Incomplete
In Progress
Application Status Approve/Disapprove Date
 -
Month
 -
Day
Year
Date
Case Status
Please Select
Open
Closed
TOTAL MONTHLY INCOME
TOTAL MONTHLY EXPENSES
TOTAL ASSETS
TOTAL DEBTS
Notes
Welcome!
Thank you for taking the time to fill out our application. We know this is a stressful time for you, so if you have any trouble filling out the information or if you have any questions, please call us at: 770-815-3581
Before you begin, we recommend gathering the following information:
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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
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
 -
Month
 -
Day
Year
Date
Gender / Sex
Please Select
Male
Female
N/A
Resident Status
*
Please Select
US Citizen
Lawful Permanent Resident
Race
Please Select
White
Native American or Alaska Native
Asian
Asian Indian
Black or African American
Native Hawaiian or Other
Hispanic or Latino
Marital Status
*
Please Select
Married
Divorced
Single
Widowed
Military Status
Please Select
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
*
Please Select
Owner
Renter
Other
Number of Adults in Household
*
Number of Children in Household
*
Number of Dependents Under 18 in Household
*
Number of Dependents Over 18 in Household
*
Number of Non-Dependents in Household
*
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Family
Number of Parents
*
Please Select
1 Parent
2 Parents
Number of Children
*
ADD FAMILY MEMBERS:
Child’s Medical Condition
*
Please Select
Heart
Autism
Transplant
Cancer
NICU
Accident
Other
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Employment
Employment Status
Please Select
Employed Full-Time
Employed Part-Time
Unemployed
Employer 1
Employer 2
Employer 3
Previous Employer
Please upload a picture of your latest pay stub:
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Finances
Monthly Household Income Information
Salary / Wages
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
If other, please name Institution
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
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
*
Family or Child Photo:
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Were you self-sufficient before your medical crisis?
Will a grant of this kind return you to self-sufficiency?
How will you maintain this self-sufficiency once the grant has expired?
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