Direct Service Financial Assistance Application
FINANCIAL ASSISTANCE PROGRAM ELIGIBILITY SCREENING & IN TAKE FORM
APPLICANT INFORMATION
Name
*
Legal First Name
Middle Initial
Legal Last Name
Click here to enter a date of birth.
*
/
Month
/
Day
Year
Date
Current Address
*
City
*
State
*
Zip Code
*
Email address
*
Race
*
Black or African American
Hispanic
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Ethnicity
*
Are you of Haitian descent?
*
Yes
No
Citizenship status
*
What year did you migrate to the United States?
*
Current resident of Florida?
*
Yes
No
Select which qualifying county you reside in.
*
Please Select
Miami-Dade
Broward
Palm Beach
Monore
Diagnosis type
*
Year of diagnosis
*
Treating Physician
*
Treating clinic/facility
*
Treating Physician phone number
*
Treating physician address
*
Do you have health insurance?
Yes
No
Are you employed?
If employed, What is the name of your employer?
Requesting financial assistance for:
*
Transportation to medical appointment
Groceries
Rent/Mortgage
Childcare
Utilities
Household Cleaning
Are you enrolled in school?
Yes
No
Name of school/program
How did you hear about us?
*
Must submit the required supporting documents:
1. Physician statement on letterhead reflecting applicant name, date of birth, diagnosis and name of treating clinic/Physician and current treatment plan
*
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2. Proof of residency (Must submit a Government ID. Government ID's accepted: State of Florida driver's license or State of Florida identification card)
*
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3. Proof of ethnicity (U.S. Passport, Other National Passport, Residency card (green card) or Birth Certificate) Must submit one.
*
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3. Current child care invoice (If applicable; must be addressed to applicant)
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4. Current rent ledger, lease agreement or signed letter from landlord (If applicable, must list applicant as renter or homeowner and must reflect address on application.)
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5. Current utility bill (If applicable, bill must reflect applicant name and address on application.)
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5. Estimate/invoice for household cleaning service (If applicable, service residence must reflect address on application.)
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Signature
*
Submit
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