Request for Financial Assistance

Request for Financial Assistance
This form is for those who are in financial hardship, directly related to Sickle Cell Disease, due to their own illness or an illness of a dependent in their care at least 50% of the time.

Please complete the following form, and submit all necessary supporting documentation. All information relating to this application is kept completely confidential and will only be used to determine eligibility.
Personal Information

Please fill out this section completely.
Full Name*

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth*

MonthDayYear
Have you applied for financial assistance from us before?*

YesNo
If you have, how much did you receive? *
General Household Information
Number of ADULTS living in the household without SCD*
Number of MINORS living in the household without SCD *
Number of ADULTS living in the household with SCD:*
Number of MINORS living in the household with SCD:*
General Financial Information

Fill out the corresponding sections that best describes your situation.
Monthly Expenses - Average amount of monthly bills*
What is the approximate total of your monthly expenses from above?*
What is the total income you receive per month?*
Assistance Request
Please fill in the amount next to the type of assistance you are requesting. (You may request multiple)*
What is the total amount you are requesting?
$USD
Supporting Documentation

We need supporting documentation of hardship or significant financial need in order to provide assistance. Please explain the documentation you are providing with this application. If assistance is related to a minor, please provide proof that the minor is in your care at least 50% of the time. Documentation can include your cut-off notice for utilities, an eviction or late notice from your landlord, late notice from your mortgage company. A print out from your pharmacy regarding non coverage of medicine, bank statements, etc. Effective August 1, 2024 if you receive over 100 dollars in assistance you will need to volunteer at one of our events for an hour. An educational event, gala, annual walk or back to school event. If you’re not able to do that we have clerical work that you can do. You will not receive any assistance until that is completed. Example: you receive 100 dollars for your water bill. You will get that bill paid, but will not receive anymore assistance until you do your volunteer work.
Explanation of Supporting Documentation
Supporting Documentation File Upload*

Cancelof
Filling out this form does not guarantee assistance. You may get some, all, or none of your requested assistance, depending on the circumstances of your application. Each application is reviewed by the Director of the STAR PROGRAM and the STAR PROGRAM COMMITTEE to ensure unbiased and fair decisions are made regarding assistance. Gift cards to Wal-Mart or Kroger will be provided for groceries. Checks will be mailed directly to the landlord, property manager, or bank. Other items may be reimbursed with proof of payment.

By submitting this application you are stating that you have been directly affected by Sickle Cell Disease, either due to your own illness or that of a dependent in your care. You have provided accurate and true information regarding your financial status and are in immediate need of assistance in order to provide basic necessities for those in your household (food, water, heat, etc).

I affirm that the information in this form is true and accurate according to my knowledge.
Signature & Agreement to Terms
Name

First NameLast Name
Date

DayMonthYear
Should be Empty:

Request for Financial Assistance

Personal Information

General Household Information

General Financial Information

Assistance Request

Supporting Documentation

Signature & Agreement to Terms