Financial Exception Request Form
This form must be completed if applicant doesn't currently qualify for Miracle Flights program services due to financials. All submissions will be reviewed and may be verified by a third party to determine accuracy. If approved, Miracle Flights will communicate next steps to you.
Name of Person Completing This Form
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Email
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example@example.com
Cell Phone Number
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Please enter a valid phone number.
Patient Full Name
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Patient Date of Birth
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/
Month
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Day
Year
Relationship to Patient
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Parent/Legal Guardian
Caregiver
Immediate Family Member
Current Household Size
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Biological parent(s), adoptive parents, or legal guardians residing in the home + sibling(s) of the child applicant + Domestic Partner, Common Law Spouse, or Intimate Partner of Parent residing in residence.
Current Household Gross Income
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Gross income of those individuals in household that are legally and financially responsible for child patient.
Why are you submitting a financial hardship request form?
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My family is unable to provide last year's IRS 1040 tax forms on the Flight Request Form.
My family has experienced overwhelming expenses due to the patient's diagnosis, which are not reflected on last year's IRS 1040 tax forms.
My family has experienced substantial financial hardship recently that is not reflected in last year's IRS 1040 tax forms (i.e. loss of employment).
Please explain the personal circumstances that prohibit you from providing your IRS 1040 form to verify your income.
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Can you verify your income by providing paycheck stubs for the last 60 days?
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Yes
No
Are you able to verify your income any other way? If so, please explain the alternative proof you may provide to verify your income.
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Can you provide us with a form of documentation/proof to verify the medical expenses that you incurred over the last 12 months in relationship to the patient for whom you are requesting assistance?
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Yes
No
Do you have any additional information you would like for us to know in relationship to your personal and/or financial circumstances? If so, please explain in the space provided below.
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Are you able to provide us with verification of the recent drop in income (such as paycheck stubs reflecting your most recent 60 day income)?
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Yes
No
Please explain the details of the reason for your recent reduced income and any other pertinent details that may assist us in understanding your circumstances and previous vs. current income?
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Verification Statement
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I verify this information to be truthful and accurate, and understand that if inaccurate and/or fraudulent information is provided it may result in the application denial or disqualification from program services in the future. A third-party verification service may be used to confirm the accuracy of the information provided.
Signature
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Signer Name
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First Name
Last Name
Signer Relationship to Patient
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Self (I am 18 or over)
Parent/Legal Guardian (Patient is 17 or under)
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