*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.
*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.
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.