Bosom Buddies of AZ Financial Assistance Application

STOP! PLEASE READ INSTRUCTIONS BELOW.

***INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED AND RECIPIENTS WILL BE REQUIRED TO RE-APPLY.***

*You will be notified when your application is complete.*

INSTRUCTIONS (ALL ARE REQUIRED):

1. FILL OUT the Grant Application below.

2. UPLOAD # 1: Copy of Photo ID (Passport, Drivers License, or Governmental ID) with ID # on Application.

3. UPLOAD # 2: Proof of Income (Last 2 Pay Stubs) or Unemployment Acceptance or Rejection Letter. Must show weekly or monthly pay rate.

4. UPLOAD # 3: Outstanding Bill (Reason for Assistance) - If rent, you must include an official bill/invoice from your Landlord. Bills must clearly show the arrears amount and date in PDF form.

5. UPLOAD # 4: Note from your doctor on their official letterhead with date, signature or your most recent Pathology Report in PDF form.

Please properly label all documents attached. Once all required documents are received, your application will be considered pending. After reviewing the documents, we will contact you directly if we have any further questions. Please note, the program is based on limited funding and may take 3-4 business weeks to be processed. If approved, payment will be sent directly to the authorized payee.

Bosom Buddies, Inc. ("Bosom Buddies") is an Arizona nonprofit corporation whose mission is to increase awareness of breast cancer through prevention and early detection, and supporting men and women and their families diagnosed with breast cancer. Unfortunately, those dealing with breast cancer and their families often face financial difficulties due to expensive medical bills and possible loss of income if they are unable to work during medical treatment.

Bosom Buddies is committed to helping those during the difficulty undergoing treatment for breast cancer through the award of grant money. The grant money is to help with essential needs based on available funding. For more information about Bosom Buddies, please contact us at (602) 265-2776.

In its decision to award its grants, Bosom Buddies relies upon the truthfulness of the information submitted in support of your application. Discovery of false information in the grant application is basis for denying the grant and revocation of any grant award if the application form contains false or misleading information. the health information contained herein shall be used for the purpose of evaluating the application and shall be kept confidential.

Bosom Buddies does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations. We are committed to providing an inclusive and welcoming and supportive environment for all of our grant applicants and recipients.

Name*

First NameLast Name

Date of Birth*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Email*

example@example.com; If no email, please enter N/A.

Emergency Contact*

First NameLast Name

Phone Number*

Area CodePhone Number

Date of your breast cancer diagnosis and describe the current treatment regimen*

example: 10/10/2022 Stage 2, in active chemotherapy treatment

Estimated annual household income for the last year*

example: $50,000

Household*

Single Parent FemaleSingle Parent MaleTwo ParentSingle Person

Head of Household?*

YesNo

Do you have medical coverage? If yes, please list what coverage you have.*

Yes, _____________________No

How many people in your household?*

What is your Housing Type*

RenterOwner

Are you Homeless?*

YesNo

If yes:

With RoofWithout Roof

Race/Ethnicity (voluntary)

Describe your need for financial assistance:*

Describe the impact this grant will make on your life:*

Please provide a referral from a medical doctor currently treating you for breast cancer:*

Upload: 1. ID 2. Proof of Income 3. Outstanding Bills 4. Dr's Note or Pathology Report. See ABOVE for details. *

Browse Files

Please make sure ALL 4 documents are property labeled and uploaded. If this section is incomplete, your application will NOT be processed.

I hereby make this declaration under penalty of perjury and represent, warrant and agree that:

1. The information submitted in support of this application is true and correct;

2. I have been diagnosed with breast cancer;

3. I am currently undergoing treatment for breast cancer;

4. I need financial assistance for essential purposes as defined on the addendum.

5. I will submit the the most updated information with my name listed on all forms to include Dr note/Pathology report, bills, income and identity verification.

6. I will assist Bosom Buddies in any and all other information needed to help with verifying information while determining the outcome of the approval process. If approved Bosom Buddies will pay directly to the financial institution and/or landlord or property manager. No funds will be paid directly to me.

7. I agree to be bound by the terms and conditions of the grant.

Signature*

Applicant Printed Name*

Date*

DayMonthYear

Bosom Buddies of AZ Grant Application

Personal Information

Signatures