EMERGENCY ASSISTANCE REQUEST FORM

EMERGENCY ASSISTANCE REQUEST FORM
Submitting this request does not guarantee payment. Approval is at the discretion of the Arizona Bleeding Disorders (Member Services Department) and is contingent on availability of funds for this program. Once the application has been submitted, please allow 1-2 weeks for processing. Assistance is limited to a maximum of $500 per 12 months with a minimum of 3 months between requests, per household. In the presence of special circumstances, the AZBD Executive Director will review exceptional requests.

Eligibility Guidelines:
- Applicant must be a resident of Arizona and an active Member of Arizona Bleeding Disorders.
- Applicant must have a diagnosed bleeding disorder or be the parent or guardian of a minor child who lives in the same household who has a diagnosed bleeding disorder.
- A copy of the outstanding bill or invoice is required and must be included with this application.
- Applicants must complete all sections of the application thoroughly and accurately and provide corresponding documentation if requested.
- Assistance is available for rent, mortgage, and utilities. Anything other than the previously mentioned must be approved by the Executive Director.
Community Member Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Members name who is diagnosed with a Bleeding Disorders
Date of Birth of diagnosed member

MonthDayYear
Date
Date of Diagnosis

MonthDayYear
Date
Other Household Members Names
Invoice Bill Information
Name of Payee
Account Number
Address of Payee

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Requested Amount
Bill Due Date

MonthDayYear
Date
Please include a copy of the bill referenced in request and any other information necessary to support your request.

Cancelof
826 N 5th Ave . Phoenix, AZ 85003 . 602.955.3947 fax: 602.955.1962 . www.arizonahemophilia.org

Arizona Hemophilia Association, Inc. is a nonprofit 501(c3) organization Tax ID 86-0209257
The AZBD's assistance program should be considered a last option. Please list three other resources you have asked for assistance prior to the Association.
1.
Telephone Number
Format: (000) 000-0000.
2.
Telephone Number
Format: (000) 000-0000.
3.
Telephone Number
Format: (000) 000-0000.
Brief description of circumstances leading to this hardship
Brief description of plan to improve the situation
I certify that the information I have provided in this application is true and correct. I consent to the release of this information in this application to the Arizona Bleeding Disorders or other social service agencies, groups, HTC's, utility companies, etc which may assist and contribute to receiving emergency assistance funds.
Print Name
Signature
Date

MonthDayYear
Date
826 N 5th Ave . Phoenix, AZ 85003 . 602.955.3947 fax: 602.955.1962 . www.arizonahemophilia.org

Arizona Hemophilia Association, Inc. is a nonprofit 501(c3) organization . Tax ID 86-0209257
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EMERGENCY ASSISTANCE REQUEST FORM

Invoice Bill Information