Pink Purse Application

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This application is for Connecticut and Long Island, New York residents ONLY

Pink Aid’s Emergency Financial Assistance (Pink Purse) provides emergency assistance to underserved breast cancer patients in financial crisis who are undergoing active treatment for a breast cancer diagnosis. Funds provide emergency assistance for non-medical household expenses once an application and all documentation has been received.

Pink Purse Fund considers the following but not limited to as Critical Non-Medical Household Expenses:
- Utilities (i.e. electricity, heat, gas and hot water)
- Phone and Cable
- Transportation to and from hospital visits and treatment centers to include Uber gift cards, gas gift cards, car loan payments and car insurance premiums
- Rent or Mortgage
Section I: Eligibility

All applications are required to be submitted by a Patient/Nurse Navigator, Social Worker or 501c3 administrator. Our policy is to work solely with a patient's social worker, we do not work directly with patients.
Today's Date*

MonthDayYear
Date
Place of Residence*
Is the patient in active treatment? Active treatment, for the purposes of Pink Aid's Pink Purse, is defined as the period after a positive breast cancer diagnosis has been made and during which therapies are being administered, including surgical procedures, to remove the cancer (e.g. single or bilateral mastectomy, lumpectomy), chemotherapy or radiation. Active treatment does not include long-term hormonal therapies such as Tamoxifen or an Aromatase Inhibitor.*

YesNo
Is the patient’s income 500% of of the Federal Poverty Level based on last year’s tax return or based on the Social Worker’s evaluation of the patient’s current situation, including sustained loss of income or inability to work directly resulting from treatment for breast cancer*

YesNo
Click here for 2025 Poverty guidelines

The patient is not eligible for Pink Purse Funding. If you have any questions, please email pinkpursect@pinkaid.org.
Section II: Required Documentation

Please review the additional documentation required to submit an application. Note that all payments are paid directly to the vendor, we do not pay patients directly. Incomplete applications will not be considered for review.
Required at the time of submission:
1. A completed application signed by Nurse Navigator, Hospital Social Worker or 501c3 Administrator.
2. A signed letter from a doctor on hospital letterhead confirming breast cancer diagnosis/active treatment.
3. A signed letter from a Nurse Navigator, Hospital Social Worker or 501c3 Administrator on hospital letterhead verifying the patient qualifies for financial assistance.
4. A billing statement dated within 30 days of this application and must relate to the patient's place of residence.
5. A current lease or Proof of Residency Form is required for rent requests.
Please note: At this time, Connecticut and Long Island, NY residents may receive up to $1,000 in a twelve month period. Applications can only be accepted in English.
Section III: Patient Information
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Date of Birth*

MonthDayYear
Primary Language Spoken*
Pink Aid hopes to better understand the patients we serve by gathering information about race and ethnic identity. Information that we obtain may be used to seek out additional funding to serve more patients through our Pink Purse Initiative. We hope you can help us by answering the following question below. Which of the following best describes you:*

Asian or Pacific IslanderBlack or African AmericanHispanic or LatinoNative American or Alaskan NativeWhite or CaucasianMultiracial or BiracialA race/ethnicity not listed hereDo not wish to answer
Marital Status*

SingleMarriedSeparatedDivorcedWidowed
Number of children under the age of 18 living in your household*
Are you currently employed?*

YesNo
Please list your occupation:
How did you hear about Pink Aid?*

Social WorkerFriendOnline SearchSocial MediaEventOther
Current Treatment
Date of Diagnosis*

MonthDayYear
Date
Hospital/Treatment Center*
If the patient will be having surgery for their breast cancer diagnosis, please provide date:

MonthDayYear
Date
If the patient is receiving chemotherapy treatments, please provide date of last treatment:

MonthDayYear
Date
If the patient is receiving radiation therapy, please provide date of last treatment:

MonthDayYear
Date
Further Information
Breast Cancer Physician*
Nurse Navigator or Social Worker*
Nurse Navigator or Social Worker Email*
example@example.com
Nurse Navigator or Social Worker Phone Number*

Area CodePhone Number
If the patient applied for Pink Purse in the past, please list date

MonthDayYear
Date
Section IV: Funding Requests/Upload Appropriate Documentation

Note: All bills must be current and within 30 days of the month requesting funds for and in the patient’s name (or spouse) and patient’s place of residency. Bills should include the account number, the current balance due and the complete address to which payments are sent. A screenshot of an account balance is not an acceptable form of documentation and we require the full statement or bill.

Please note that bills will be verified prior to payment and that Pink Purse does not pay directly to individuals.

REMINDER: Connecticut and Long Island, NY residents may receive up to $1,000 in a twelve month period.
A signed letter from doctor on his/her letterhead confirming breast cancer diagnosis including date of latest treatment*

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A signed letter from a Nurse Navigator, Hospital Social Worker or 501c3 Administrator on hospital letterhead verifying the patient has been screened and qualifies for financial assistance*

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A current and accurate billing statement/invoice that supports the month being requested for funding and the complete address to which payments are sent (Bill requested must be for the patient’s place of residence)*

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The application process will not contunue until the required documentation is loaded.
A current lease or our Proof of Residency Form, if requesting a rent payment.

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If you are applying for transportation assistance, please select one of the following and explain why it is needed in the space below. Note: we can only fund transportation requests directly associated with travel to and from breast cancer treatment with a maximum of $200 in Uber or Gas Cards.
For eligible patients we can offer gas gift cards at the following gas stations, please select one:

Exxon/MobilShellSpeedway
Please explain why transportation assistance is needed in the space below:
Name and Location of Gas Station (keep hidden to save old data in files): eg. Shell Gas Station in Plainville, Texas
Please prioritize bills in order of importance to the patient.
First Bill
Vendor name, month and amount requested for funding.
Second Bill
Vendor name, month and amount requested for funding.
Third Bill
Vendor name, month and amount requested for funding.
Beyond applicant’s financial needs, describe any special circumstances that our Pink Purse committee should take into consideration when reviewing the application:
Section V: Signature and Submit

Disclaimer: Section II above contains the complete list of the documentation required for this application. Any other documentation submitted that is not listed in Section II is not necessary for Pink Aid to make a determination and will be deleted from our files.

All applications are required to be submitted by a Patient/Nurse Navigator, Social Worker or 501c3 administrator.
Social Worker/Hospital Navigator Name*
Social Worker/Hospital Navigator Signature*

Clear
By signing this application, you are certifying that the information and statements contained (including any other material and information submitted) are true and correct and that you give PINK AID permission to contact a payee should we have additional questions.

Although we encourage you to submit your application online, you can also scan your application and supporting documents to: pinkpursect@pinkaid.org or mail to Pink Aid, PO Box 5157, Westport, CT 06881.

Instructions on how to save this form: Click Save, Select "do not create account" and insert the email address for the person finishing or retrieving the application.
Should be Empty:

Persons in Family/Household	500% Threshold for Pink Purse Eligibility
1	78,250
2	105,750
3	133,250
4	160,750
5	188,250
6	215,750
7	243,250
8	270,750

Section II: Required Documentation

Section III: Patient Information

Current Treatment

Further Information