Pink Purse Application

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This application is for patients who reside OUTSIDE of Connecticut and Long Island, New York

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.

Please note our Pink Purse is open Monday – Thursday 9am-5pm EST and Friday 9am-12pm EST. Please do not submit applications after business hours as our system will not recognize and/or accept the application and therefore will not be reviewed. At this time due to high volume, increased demand, and our monthly budget limits, we require that applicants submit only one bill of $300 or more to be considered for Pink Purse funding. Unfortunately, bills under $300 cannot be reviewed. We appreciate your understanding as we work to manage the incredible influx of applications we are receiving. Kindly submit applications during our open hours as the pink purse is here to help.

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
Section I: Eligibility

All applications are required to be SUBMITTED BY a Certified 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 household income 500% of the FEDERAL POVERTY LEVEL based on last year's federal tax return?*

YesNo
Is the patient's household income 300% of the FEDERAL POVERTY LEVEL based on last year's federal tax return?*

YesNo
If you checked YES you may be eligible for the Compassion Plus Award (CPA) for the most dire breast cancer patients in active treatment and who would benefit from mortgage/rental assistance. If you choose this award you may NOT also apply for the regular Pink Aid grant for household expenses. Patients are only permitted to choose one of these applications per 12 month period. Please click here for the application: https://form.jotform.com/241285205796159
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 a Hospital Social Worker, Nurse Navigator, Certified Patient Navigator 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 Hospital Social Worker or Nurse Navigator 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.
Please note: At this time, qualified patients may receive up to $500 once 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
Diagnosis*
Stage 1, Stage 2, etc.
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 and must be over $300. At this time due to high volume, increased demand, and our monthly budget limits, we require that applicants submit only one bill of $300 or more to be considered for Pink Purse funding. Unfortunately, bills under $300 cannot be reviewed. We appreciate your understanding as we work to manage the incredible influx of applications we are receiving. 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: All qualified patients may receive up to $500 once 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 Hospital Social Worker or Nurse Navigator on hospital letterhead verifying the patient 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). Minimum Bill Amount $300.At this time due to high volume, increased demand, and our monthly budget limits, we require that applicants submit only one bill of $300 or more to be considered for Pink Purse funding. Unfortunately, bills under $300 cannot be reviewed. We appreciate your understanding as we work to manage the incredible influx of applications we are receiving. We will be funding ONE BILL ONLY so please be sure to submit a bill that is the closest to our maximum $500 allotment. If there is an additional name on the bill, please explain their relationship to the patient. *

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The application process will not contunue until the required documentation is loaded.
If your patient could benefit from a transportation gift card grant, select one of the following. Note: we can only fund transportation requests directly associated with travel to and from breast cancer treatment. GAS cards can ONLY be considered along with a patient's request and bill FOR A CAR LOAN OR CAR INSURANCE PAYMENT.
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
Bill Detail
Vendor name, vendor address, month and amount requested for funding.
Bill Detail
Vendor name, month and amount requested for funding.
Bill Detail
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 Certified Patient/Nurse Navigator, Hospital 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:

Section II: Required Documentation

Section III: Patient Information

Current Treatment

Further Information