CK Emergency Assistance Grant Program Application

EMERGENCY ASSISTANCE GRANT PROGRAM
Eligibility Requirements:

*Must be a parent or guardian of a minor child who lives in your home and who has a diagnosis of a chronic inherited bleeding disorder OR be an individual with a diagnosis of a chronic inherited bleeding disorder.

*Must be a United States citizen or legally living permanently in the United States

*Must have an emergency financial need of $750 or less. Acceptable requests are:

➢ Utility bill

➢ Medical bill

➢ Auto repairs

➢ Home repairs

➢ Emergency transportation services due to bleeding disorder

➢ Other expense deemed appropriate by the Colburn-Keenan Foundation, Inc. (CKF)

*No one in the household must have received an Emergency Assistance Grant or Individual Assistance Grant from CKF over the past 365 days.

*The attached application, financial statement & medical verification must be completed in their entirety and returned along with a copy of the invoice you are requesting assistance with.

Additional Information:

*Emergency financial assistance is limited to a maximum award amount of $750 per application. Any household that has received an Emergency Assistance Grant for three consecutive years, will be ineligible for one year.

*If after receiving this grant you find yourself in additional financial need, you MAY apply to the Individual Assistance Grant Program that CKF offers, but will need to supply a statement as to why you applied to both within a 365 day period.

*Submission of an Application, does NOT guarantee an award. Applications for emergency financial need will be reviewed and either approved or denied by CKF and is dependent on the availability of funds. All decisions are final.

*CKF does not provide funding directly to the applicant. Any award payment will be mailed directly to the vendor with a copy of the payment letter being mailed to the applicant. CKF is not responsible for any account that defaults due to late payment and is also not responsible for any cancellation of service or coverage.

Our Emergency Assistance Grant Program, provides emergency assistance to individuals and families who are United States citizens or legally living permanently in the United States and who are affected by chronic inherited bleeding disorders.

Instructions:

1. Do not leave any line of the application of financial statement blank. Write “N/A” if not applicable.

2. Sign & date pages 3 AND 4.

3. Obtain a signed medical verification form (must use our form found on page 5)

4. Email, fax or mail your application, financial statement, medical verification form and copy of the invoice you are requesting assistance with. The copy of the invoice must be in its entirety with payment coupon attached (if applicable). Screen shots of your account will not be accepted.

If you have any questions while completing the application, please call.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email*
example@example.com
How many adults (ages 18+) reside in the household?*
How many children (under 18) reside in the household?*
Diagnosis
Full Name (first, middle initial, last)of the individual in the household with the bleeding disorder:*
What is the diagnosed bleeding disorder?
Relationship to the Applicant:
Date of birth of person with diagnosed bleeding disorder

MonthDayYear
Date
Request
What invoice(s) are you requesting assistance for?
If a monthly expense, what are you doing to ensure that this bill will be paid next month?
Is this a one-time expense or monthly expense?
What is the amount you are requesting?
If the amount due is over $750, how will you pay the difference?
When is payment due?
Have you applied to any other organization for assistance for this particular invoice?
If yes, what decision did they make?
Brief description of circumstances leading to this financial hardship:
I confirm that the information provided on this application form and in all supporting documentation is complete and accurate. I understand that grant assistance is not guaranteed. I understand that, if my grant request is approved, payments will be sent directly to the vendor to which they are due. I understand that it is my responsibility to ensure that my accounts do not default due to the grant payment not being able to be sent out ahead of the due date. The Colburn-Keenan Foundation, Inc. is not responsible for any cancellation of service or coverage. If approved, I agree to promptly return to the Colburn-Keenan Foundation, Inc. any refund check from a company due to overpayment resulting from grant funds.

By signing, I attest that I have read the above and agree to abide by the policies of the Emergency Assistance Grant program as outlined in this application and through all other correspondence with the Colburn-Keenan Foundation, Inc. I attest that I am a United States citizen or legally living permanently in the United States.
Applicant's Signature

Clear
Today's Date

MonthDayYear
Date

EMERGENCY ASSISTANCE GRANT PROGRAM FINANCIAL STATEMENT
I, Applicant's Full Namehereby declare that I am not able to meet my financial responsibilities for the requested invoice.
I am applying for a one-time emergency assistance grant through the emergency assistance grant through the Colburn-Keenan Foundation, Inc. in the amount of $
(Dollar amount not to exceed $750). I submit the following financial statement:
Monthly Net Household Income (include employment, self-employment, unemployment benefits, social security, disability benefits, child support and alimony, etc.)
Applicant:
Dollar Amount
Spouse/Partner:
Dollar Amount
Additional Household Member:
Dollar Amount
Additional Household Member:
Dollar Amount
Additional Household Member:
Dollar Amount
Total Monthly Income
Monthly Food Stamps:
Dollar Amount
Monthly Public Assistance (What & how much):
Monthly Householf Expenses:
Mortgage/rent:
Dollar Amount
Homeowner's Insurance:
Dollar Amount
Property Taxes (if not escrowed in mortgage):
Dollar Amount
Utilities (electric, heat, etc.):
Dollar Amount
Cable and/or internet:
Dollar Amount
Home Phone:
Dollar Amount
Cell Phone:
Dollar Amount
Medical Insurance (if not a deduction out of pay):
Dollar Amount
Auto Loan #1:
Dollar Amount
Auto Loan #2:
Dollar Amount
Auto Insurance:
Dollar Amount
Gas for Auto:
Dollar Amount
Public transportation expenses:
Dollar Amount
Education expenses:
Dollar Amount
Childcare expenses:
Dollar Amount
Groceries/Food:
Dollar Amount
Addt'l Expense:
Dollar Amount
Addt'l Expense:
Dollar Amount
Addt'l Expense:
Dollar Amount
TOTAL MONTHLY EXPENSES:
Please upload bill or invoice that you are requesting to be paid.

Cancelof
By signing, I certify that the financial information I have provided above is true and accurate.
Applicant's Signature

Clear
Today's Date

MonthDayYear
Date

Should be Empty:

EMERGENCY ASSISTANCE GRANT PROGRAM

Diagnosis

Request

EMERGENCY ASSISTANCE GRANT PROGRAM FINANCIAL STATEMENT