Mary E Smith Foundation Financial Assistance Grant Application

MARY E. SMITH (M.O.M) FOUNDATION, INC./ MEMORIES OF MARY

FINANCIAL ASSISTANCE GRANT
FINANCIAL ASSISTANCE GRANT APPLICATION

ELGIBILITY: All applicants must be U.S. residents. Candidates must be the brain tumor patient; parent/guardian of; or a financially bound relative of a person diagnosed with a brain tumor. Relationships are limited to spouse, children, parents, and siblings. All applications require the signature of the patient/next of kin; parent/guardian and must be accompanied by proof of a brain tumor diagnosis such as hospital statement showing services related to diagnosis. Supporting documentation regarding financial hardships during and/or following the diagnosis should also accompany the application (ex. past due hospital bills).

Note: Funds will be distributed on a first come first serve basis (check website for availability Funds are made payable to the patient or next of kin if patient has transitioned; parent/guardian. Maximum amount awarded is $2500.00.
A.“A HUSBANDS HOPE” Must be the HUSBAND of the brain tumor patient. Must demonstrate financial hardship during and/or after the diagnosis.

B. “A WIFE’S WISH” Must be the WIFE of the brain tumor patient. Must demonstrate financial hardship during and/or after the diagnosis.

C. “A CHILD CARES” Must be age 18 or older. Must be the CHILD of the brain tumor patient. Must be a caretaker of the brain tumor patient. Must demonstrate financial hardship during and/or after the diagnosis.

D. "MY BROTHER'S/SISTER'S KEEPER" Must be age 18 or older. Must be the SIBLING of the brain tumor patient. Must be a caretaker of the brain tumor patient. Must demonstrate financial hardship during and/or after the diagnosis.

E.“A PERSISTENT PATIENT/PARENT” Must be a brain tumor SURVIVOR or parent/guardian of a minor previously or currently diagnosed with a brain tumor. Must demonstrate financial hardship during and/or after the diagnosis.
GRANT TYPE:
Choose One:*

Husband's HopeWife's WishChild CaresMy Brother's/Sister's KeeperPersistent Patient/Parent
APPLICANT INFORMATION:
Full Name*
Email
example@example.com
Relationship to patient*
If not the patient
Applicant Email *
Where response should be sent example@example.com
Applicant Home/Mobile Phone *
For applicant to be contacted
PATIENT INFORMATION:
Patient First Name *
If different from the applicant name
Patient Middle Name
Patient Last Name*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home/Mobile Phone
Email
example@example.com
DIAGNOSIS INFORMATION
Diagnosis (close to original date as possible)*

MonthDayYear
Date
Type of Tumor*
Hospital/Facility Name *
Where diagnose of the tumor occurred or where treatment is being provided
Address

Facility Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip code
Phone
GRANT AMOUNT REQUESTED*
Not to exceed $2500
Statement regarding how you plan to utilize the grant funds.*
APPLICANT ATTESTATION

I have read and understand the terms of this financial award and will comply with all the requirements. If selected as a grant recipient, it may be necessary to provide additional information and/or verification to Mary E. Smith (M.O.M) Foundation, Inc./Memories of Mary. I further agree to grant permission to my healthcare provider/facility to disclose mine or my loved one's diagnosis. If I am the patient, I certify that I willingly provided my medical information solely for the purpose of gaining financial support. I agree to the use of my initials or last/family name & abbreviated situation to be shared in MESF materials/website regarding award distributions by MESF to the charities donors/support base. I/We certify that the information provided is accurate to the best of my/our knowledge.
I agree with the above statement and will provide the date & my signature below...*

YESNO, I do not agree
Today's Date*

MonthDayYear
Date
Signature

Clear
FILE UPLOAD (Please provide proof of diagnosis, copies of past due bills & other receipts that total the amount being requested.)

Cancelof
Should be Empty:

MARY E. SMITH (M.O.M) FOUNDATION, INC./ MEMORIES OF MARY

GRANT TYPE:

APPLICANT INFORMATION:

PATIENT INFORMATION: