CERTIFICATION OF INFORMATION PROVIDED
I hereby certify, under penalty of perjury, that the information set forth on this applica- tion concerning my income, liabilities and insurance provider is true and accurate and that the expenses for which I have requested financial assistance impose a financial hardship for me. Further, I have been diagnosed with cancer, I am undergoing treat- ment for, or I have recently undergone treatment for cancer, and I do not have adequate resources or income to pay for the expenses. I reside in Delaware, and I am a citizen of the United States. I understand that if any of the information set forth above is false, that my application will be null and void. By signing below, I hereby grant and give permission for representatives of Cancer Sup- port Community Delaware to contact my physician(s) and/or medical team member(s) as needed.