Financial Assistance Application
Brain tumor and brain cancer patients who wish to apply for Mission4Maureen assistance must complete all required fields of this form. Once submitted, you may expect a determination within 3-5 weeks depending on time of the year and available funds.
Financial Need
Mission4Maureen provides financial assistance up $1,500 per applicant by paying bills/expenses on behalf of qualified recipients. Examples of qualifying bills/expenses include rent/mortgage, electric, natural gas, phone, auto loan/lease, auto or home repairs, insurance, medical, credit.
Applicant Name
*
First Name
Last Name
Total Amount Requested
*
Total of three (3) bills, not to exceed $1,500 in total.
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Email
*
example@example.com
Best Time to Be Contacted
*
Bill Payment Requests
Applicants may submit up to three bills for financial assistance totaling no more than $1,500. A copy of each bill payment request MUST be uploaded to be considered.
Bill Payment Request #1 Amount
*
Bill Payment Request #1 Business Name (e.g. GM Financial)
*
Please Upload Copy of Bill Payment Request #1
*
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Bill Payment Request #2 Amount
Bill Payment Request #2 Business Name (e.g. GM Financial)
Please Upload Copy of Bill Payment Request #2 (Note: Copy of Bill/Payment is required for approval.)
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Bill Payment Request #3 Amount
Bill Payment Request #3 Name (e.g. GM Financial)
Please Upload Copy of Bill Payment Request #3 (Note: Copy of Bill/Payment is required for approval.)
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Patient Information
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Referred By
Photo Upload (Please share a photo of yourself or a photo of yourself with your family)
*
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Narrative (Please share your story in the space provided. 500 words maximum)
*
Note: The board has no way of knowing you except through this application.Therefore, we would like you to tell us about your brain tumor journey and about yourself, your family and your most immediate urgent needs so that we might better understand your need for our assistance.
0/500
Medical Information
Please upload a copy of your pathology/MRI report for verification purposes.
*
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Note: A screenshot from a cell phone is NOT acceptable. A letter from doctor's office is NOT acceptable. An image/scan of a brain tumor or head scar is NOT acceptable. A hospital report clearly showing the patient's name and date of birth, the name of the hospital, and the diagnosis of a brain tumor is required.
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Physician Name
*
Hospital/Organization
*
Phone Number
*
Please enter a valid phone number.
Nurse/Social Worker
Hospital/Organization
Phone Number
Please enter a valid phone number.
Personal & Family Information
Marital Status
*
Please Select
Single
Married
Divorced/Separated
Household Size (including adults and children/dependetns)
*
Employment Status
*
Please Select
Employed
Unemployed
Total Household Income (including all persons living in household)
*
Please Select
$0-$30,000
$31,000-$60,000
$61,000-$90,000
$91,000-$120,000
$120,000+
Financial Information
Mission4Maureen is a tax-exempt, non-profit foundation. As such, Mission4Maureen may engage only in those activities, which are charitable in nature. Mission4Maureen may provide grants to individuals to “provide financial relief ” or to aid individuals in“distress.” The information, which you provide, on this Net Worth Statement will be used exclusively by the foundation to determine your eligibility for financial assistance. The foundation will not disseminate or release the provided information to outside sources without first obtaining your prior express consent. The following information is being submitted by the applicant in consideration of possible financial assistance.
Cash on Hand
*
Checking Account
*
Savings Account
*
Other Liquid Assets (e.g. Investments)
*
Monthly Liabilities/Payments
If none, enter zero.
Student Loans
*
Mortgage or Rent
*
Other Loans (e.g. home equity, etc.)
*
Credit Card(s)
*
Auto Loan/Lease
*
Utilities (e.g. water, electricity, natural gas)
*
Plans/Subscriptions (e.g. cell phone, internet, etc.)
*
Other Expenses
*
Medical Release
I understand and grant my permission to all my doctors, social workers, clinics and hospitals to release all healthcare and billing information relating to my treatment and care for brain cancer and other related health problems to the Mission4Maureen Foundation. I also grant my permission to discuss the above information with any designated representative of Mission4Maureen by phone. Mission4Maureen agrees that all medical information will remain confidential, and any reports written about the program will not use any participants’ names without their express permission. I specifically authorize the release of all my healthcare and billing information in your organization’s possession. The purpose of my request is to assist Mission4 Maureen in determining my eligibility for financial assistance. This Release and Authorization shallexpire twelve (12) months from its execution if not revoked prior thereto. Mission4Maureen will not disseminate or release these medical records to any outside source without first obtaining prior express consent. I understand and agree that fulfillment of assistance may result in publicity whether or not Mission4Maureen actively takes steps to publicize its service. I understand and recognize that the granting of any service and the participation of any person in the assistance is contingent upon approval by Mission4 Maureen. I also understand that there is a limit to the number of services that I will receive, depending on the type and cost of service being requested and offered. I understand and agree that no promises or assurances whatsoever have been made to me by any representatives of Mission4Maureen regarding the assistance I am requesting.
Publicity Notice/Release
Mission4Maureen may hold events and fundraisers throughout the year to raise money to fund the primary objective of the foundation: to help families endure the staggering cost of brain cancer treatment. People continue to support us because they want to see their money fund its way to the people who need it the most. We need your help to put a face and a name to that reality. To this end we will use your photo, your name, and your submitted story. If your application is approved, Mission4Maureen may also use a brief description of how the assistance that you received has helped you. This will facilitate communication with our donors and help in attracting more contributors. Please acknowledge this notice-release by e-signing below: I hereby acknowledge that Mission4Maureen may use my name, photo, background and story in PR and marketing materials which will include, but not be limited to, its newsletters, website, mailings and general information brochures.
Terms of Agreement
*
By checking this box I acknowledge I have read and agree to the medical release and publicity notice release above.
By signing this document, I agree that the information is accurate
.
Name
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
Date
Signature
*
Please verify that you are human
*
Submit
Office Use Only
Amount Awarded
Bill #1 Payment Amount
Bill #1 Payment Name
Bill #1 Payment Reference ID
Bill #1 Payment Receipt
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Bill #2 Payment Amount
Bill #2 Payment Name
Bill #2 Payment Reference ID
Bill #2 Payment Receipt
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Bill #3 Payment Amount
Bill #3 Payment Name
Bill #3 Payment Reference ID
Bill #3 Payment Receipt
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Application Closed
Please Select
Yes
Missing Information
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