Pink Purse Application

Compassion Plus Award
Today's Date*

MonthDayYear
Date
Place of Residence*
Is the patient in active treatment? Active treatment, for the purposes of Pink Aid's Pink Purse, is defined as the period after a positive breast cancer diagnosis has been made and during which therapies are being administered, including surgical procedures, to remove the cancer (e.g. single or bilateral mastectomy, lumpectomy), chemotherapy or radiation. Active treatment does not include long-term hormonal therapies such as Tamoxifen or an Aromatase Inhibitor.*

YesNo
YesNo
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The patient is not eligible for Pink Purse Funding. If you have any questions, please email pinkpursect@pinkaid.org.
Section II: Required Documentation

Please review the additional documentation required to submit an application. Note that all payments are paid directly to the vendor, we do not pay patients directly. Incomplete applications will not be considered for review.
Required at the time of submission:
1. A completed application signed by a Hospital Social Worker, Nurse Navigator, Certified Patient Navigator or 501c3 Administrator.
2. A signed letter, dated within 60 days of the application, from a doctor on hospital letterhead confirming breast cancer diagnosis/active treatment.
3. A signed letter, dated within 60 days of the application, from a Hospital Social Worker or Nurse Navigator on hospital letterhead verifying the patient qualifies for financial assistance.
4. A current mortgage statement or a current executed lease by both parties or a notarized Proof of Residence Form is required to review this request and to be eligible for funding.
Section III: Patient Information
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Date of Birth*

MonthDayYear
Primary Language Spoken*
Asian or Pacific IslanderBlack or African AmericanHispanic or LatinoNative American or Alaskan NativeWhite or CaucasianMultiracial or BiracialA race/ethnicity not listed hereDo not wish to answer
SingleMarriedSeparatedDivorcedWidowed
Number of children under the age of 18 living in your household*
YesNo
Please list your occupation:
Social WorkerFriendOnline SearchSocial MediaEventOther
Current Treatment
Date of Diagnosis*

MonthDayYear
Date
Diagnosis*
Stage 1, Stage 2, etc.
Hospital/Treatment Center*
If the patient will be having surgery for their breast cancer diagnosis, please provide date:

MonthDayYear
Date
If the patient is receiving chemotherapy treatments, please provide date of last treatment:

MonthDayYear
Date
If the patient is receiving radiation therapy, please provide date of last treatment:

MonthDayYear
Date
Further Information
Breast Cancer Physician*
Nurse Navigator or Social Worker*
Nurse Navigator or Social Worker Email*
example@example.com
Nurse Navigator or Social Worker Phone Number*

Area CodePhone Number
If the patient applied for Pink Purse in the past, please list date

MonthDayYear
Date
Section IV: Funding Requests/Upload Appropriate Documentation

Note: A patient that is in any phase of eviction proceedings cannot be considered for CPA grant funding. Rent and Mortgage bills submitted must be current and within 30 days of the month requesting funds for and in the patient’s name (or spouse) and patient’s place of residency. Please note, payments from Pink Aid are made by paper check and can take up to 2 weeks to arrive. If your bill must be paid by a portal or other digital platform we cannot support your application. Bills should include the account number, the current balance due and the complete address to which payments are sent. A screenshot of an account balance is not an acceptable form of documentation and we require the full statement or bill. If there is an additional name on the bill, please explain the relationship to the patient.

Please note that bills will be verified prior to payment and that Pink Purse does not pay directly to individuals.
A signed letter, dated within 60 days of the application, from doctor on his/her letterhead confirming breast cancer diagnosis including date of latest treatment*

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Cancelof
A signed letter, dated within 60 days of the application, from a Hospital Social Worker or Nurse Navigator on hospital letterhead verifying the patient qualifies for financial assistance.*

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Cancelof
A current mortgage statement, a current lease or proof of residency that supports the month being requested for funding and the complete address to which payments are sent (bill requested must be for the patient’s place of residence). If there is an additional name on the bill, please explain the relationship to the patient.*

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Cancelof
The application process will not contunue until the required documentation is loaded.
Section V: Compassion Plus Award

A qualified "Compassion Plus Award" patient can only receive this grant once. This award is for rent and mortgage assistance for the most dire breast cancer patients who are undergoing active treatment and are in financial crisis. Applications are only evaluated once fully completed documentation has been received. Your application will be ineligible and not considered for review if your applications is incomplete.
Social Worker Statement: Please explain why you are proposing this patient from among all those in your caseload?
Patient Statement: In 5-10 sentences please express your financial need and describe how this grant will provide you with financial relief. Include details about your household, employment and other any considerations that are impacting your situation.
Please mark the number that indicates your response as it applies to the past 7 days. Scale of 0-5 with 0 being Not At All and 4 being Very Much:

1. I worry about financial problems I will have in the future as a result of my illness or treatment.

	0	1	2	3	4	5

0 is Worst, 5 is Best

2. I feel financially stressed

	0	1	2	3	4	5

0 is Worst, 5 is Best

3. My illness has been a financial hardship to my family and me.

	0	1	2	3	4	5

0 is Worst, 5 is Best

Section VI: Signature and Submit

Disclaimer: Section II above contains the list of documentation required for this application. Any other documents submitted that are not necessary for Pink Aid to make a determination will be deleted from our files. Further documents may also be requested for evaluation at a later date.

All applications are required to be submitted by a Certified Patient/Nurse Navigator, Hospital Social Worker or 501c3 administrator.
Social Worker/Hospital Navigator Name*
Social Worker/Hospital Navigator Signature*

Clear
By signing this application, Pink Aid Pink Aid protects the privacy of recipients but reserves the right to use anonymous biographical information in marketing materials and you are certifying that the information and statements contained (including any other material and information submitted) are true and correct and that you give PINK AID permission to contact a payee should we have additional questions.

Although we encourage you to submit your application online, you can also scan your application and supporting documents to: pinkpursect@pinkaid.org or mail to Pink Aid, PO Box 5157, Westport, CT 06881.

Instructions on how to save this form: Click Save, Select "do not create account" and insert the email address for the person finishing or retrieving the application.
Type a question
Should be Empty:

Compassion Plus Award

Section II: Required Documentation

Section III: Patient Information

Current Treatment

Further Information