Lungs Matter Grant Application Form

Welcome to the Lungs Matter APPLICATION for the home radon mitigation support.

Applications cannot be reviewed by the grant commitee untill all proper documentation required is provided by the applicant.

Name*

First NameLast Name

E-mail*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

This grant is for individuals who have either been diagnosed with lung cancer or meet moderate to low-income eligibility.

All documentation requested is required before your application can be reviewed by the grant commitee.

All applicants will be required to upload the following documents:

C-NRPP (CANADIAN – NATIONAL RADON PROFICIENCY PROGRAM) approved radon test results. This is a long-term 3 month test kit. Homeowner level digital monitors do not qualify. APPLICATIONS CANNOT BE ACCEPTED WITHOUT THIS DOCUMENTATION

mitigation quote

Applicants who are applying based on the income criteria need to upload the following document:

notice of income assessment
Income tax assesment (previous tax year)
If you are a multi person home an income assesment is needed from all adults living in the household. Please provide us with documentation for the entire household income and not just one individual.

Applicants who are applying based on the diagnosis of lung cancer need to upload the following document:

Proof of diagnosis (ex. letter from doctor)
Or a referral from CancerCares Manitoba
To authorize The Lung Association of Manitoba Inc. to request required information from CancerCares Manitoba for the Lungs Matter Grant. Please submit the form Listed Here: https://www.cancercare.mb.ca/export/sites/default/Patient-Family/.galleries/files/your-information-files/Consent-to-Disclose-PHI.pdf

Applications will be reviewed monthly by a review committee. Selected applicants will be notified of their grant applications' success when funds become available. Applicants who are not selected need not apply again as their application will remain in the selection pool and be re-assessed the following month.

Have you or anyone in your home been diagnosed with lung cancer?*

yesno

Eligibility for this grant is aligned with the Community Volunteer Income Tax Program (CVITP), using the following income thresholds. Which category do you fall under?*

Single income earner with annual income under $35,0002 persons with combined annual income under $45,000 (each additional dependent add $2,500)3 persons with combined annual income under $47,500 (each additional dependent add $2,500)other

Please enter your radon level on your long-term radon test report before mitigation, showing your radon level is above 200 Bq/m3

Number of occupants living in the home requiring mitigation.*

Ages of each of the occupants in the home

Please state the cost before sales taxes based on a quote from a radon mitigation professional.

UPLOAD THE FOLLOWING DOCUMENTS:

1) Notice of Assessment OR Proof of diagnosis

2) Results from 3 month long-term C-NRPP certified radon test report

3) Mitigation quote (from a C-NRPP professional)

UPLOAD - notice of assessment OR proof of diagnosis*

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UPLOAD - Long-term radon test report*

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UPLOAD - Radon mitigation quote (from a C-NRPP professional)*

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The following questions are optional, they will provide some statistical information for The Lung Association, Manitoba Inc.

Have you delayed mitigating your home due to the costs associated with mitigation?

yesno

Does this grant increase your ability to implement mitigation in your home?

yesno

Are you a permanent resident or Canadian citizen?

yesno

Do you or anyone in your house smoke?

yespreviouslyno

Has Covid-19 increased your interest in testing for radon in your household?

yesno

How did you hear about this grant?

Please verify that you are human*

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