Financial Assistance Application Form

Financial Assistance Application

Contact Information:

Name:*

First NameLast Name

Are You a U.S. Citizen?*

Must be a U.S. Citizen to Apply.

Address:*

Street Address

Street Address 2

CityState

Zip Code

Phone:*

Email:*

example@example.com

Age:*

Number of Children:*

Include all children under 20 years old

Ethnicity:

Optional

Marital Status:

Optional

Healthcare Information:

Date of Diagnosis:*

Date

Diagnosis:*

Oncologist:*

May we contact your oncologist?*

Are you currently undergoing active treatment surgery chemotherapy and/or radiation?*

YesNo

Please describe your treatment plan (surgery, chemotherapy, and/or radiation):*

Length of treatment (include specific dates and timeframe):*

Treatment Facility:*

Insurance Provider:*

Monthly Income:

Past 12 Months Earnings:*

For self and spouse

Monthly Net Earnings:*

For self and spouse

Other Monthly Household Income (Amount):

For self and spouse

Other Monthly Household Income (Details):

Please explain, for example: child support, alimony, rental income, 401k, etc.

Total Monthly Household Income:

This total is calculated for you, based on the entries above.

Do you own any property other than you primary residence?*

Current Balances:

Checking Account:*

Current balance

Savings Account:*

Current balance

Have you received assistance in the past 12 months from other charitable organizations, churches, etc? if yes:

Total Amount Received:

Current balance

From Whom:

Monthly Expenses:

Rent/Mortgage Payment:*

Phone Bill:*

Cable Bill:*

Electric/Gas Bill:*

Water/Sewer Bill:*

Groceries & Food:*

Car Payment:*

Gas/Fuel Expenses:*

Car Insurance:*

Property Insurance:*

Property Taxes:*

Heath Insurance:*

Life Insurance:*

Other Medical Expenses (Amount):

Other Expenses (Amount):

Medical & Other Expenses (Details):

Please explain any additional medial or other expenses, for example: child support, alimony, church tithe, school tuition, etc.

Total Monthly Expenses:

This total is calculated for you, based on the entries above.

Employment Information:

Are you currently working (select one)?*

YesNoRetiredDisabled

If not currently working describe reason:

Employer:*

Employer Address:

Phone:

Short-Term Disability (select one)?*

AppliedReceivingNot Applicable

What is your Primary financial need right now (select one)?*

Please describe your request for assistance with household bills in detail and outline your need (include amounts of any past due bills). Medical bills are not an expense covered through The Meggs Foundation:*

Please describe how the onset of your medical treatment has impacted your ability to pay your bills, including lost wages, limited ability to work, poor insurance coverage, etc.:*

Please list your name if you are filling out this application on behalf of applicant:

State your relationship to the applicant and contact info:

How did you hear about The Meggs Foundation?*

Supporting Documents:

Please upload all of the following documents required to complete your application. If for some reason you are unable to upload them here, please contact us at info@themeggsfoundation.org.

Driver's License or State ID Card:

Letter of Support:

Proof of patient eligibility; a letter of support from doctor, nurse or social worker.

Bills to be Paid:

Please upload copies of invoices to ensure financial assistance payments are attributed to the correct account(s).

Bank Statements:

Please upload the last 3 months of bank statements from all adults residing in house.

Federal Income Tax Return:

Please upload a copy of your most recent Federal Income Tax Return.

Federal Income Tax Return and W-2s:

Please upload a copy of your most recent Federal Income Tax Return and W2s for all members of the household of working age.

Pay Stub:

Please upload a copy of your most recent pay stub.

Other Income & Investment Accounts:

Please upload proof of any other applicable income for each individual living in the household, including copies of statements for 401ks, IRAs, HSAs, HRAs, FSAs, stocks, bonds and any other, if they exist.

Lease or Rental Agreement:

Please upload a copy of current rental agreement or lease.

Assistance Request / Applicant Statement / Release / Affirmation

I do agree to release to The Meggs Foundation II, Inc. ("The Meggs Foundation") or its duly authorized representative, any information deemed necessary to complete its investigation of my application for financial assistance and as may be reasonably required to assist myself and my family. As an inducement to The Meggs Foundation to consider supplemental financial support in conjunction with the medical treatment of the applicant named above the undersigned does hereby affirm as follows:

1. The term "non-medical expenses" is understood to mean those reasonable and necessary expenses incurred by the family of the above-named Applicant or the above-named Applicant, in conjunction with that Applicant receiving medical treatment. Financial assistance will be provided, with the use of said funds to be specified by the Meggs Foundation. Bills cannot be in another person's name or be on an automatic payment system with creditor.

2. The undersigned acknowledges(s) and agree(s) to maintain records that will be made available to The Meggs Foundation upon reasonable request, detailing the expenditures made from the funds provided by the organization.

3. The following supporting documents for assistance must be filed/attached with this application:

Copy of driver's license or state identification card;
Proof of patient eligibility; a letter of support from doctor, nurse or social worker;
Copy of bills to be paid (please submit photocopy of invoice to ensure financial assistance payment attributed to the correct account);
Photocopy of Bank statements from all adults residing in household (3 months);
Photocopy of most recent Federal Income Tax Return and W2 for all members of the household of working age;
Photocopy of last pay stub;
Any other applicable income for each individual living in the household including copies of statements for 401k's, IRA's, HSA's, HRA's, FSA's, stocks, bonds and any other, if they exist; and
Photocopies of current rental agreement or Lease.

*Payments made for patients may require an IRS form W-9 to be completed by The Meggs Foundation.

The Meggs Foundation will pursue restitution for financial assistance if it is determined that the information submitted on the application is false.

I have read the guidelines for financial assistance, and I declare that the information furnished on this application form, including attached sheets, is true and correct to the best of my knowledge.

For good consideration which I acknowledge, I irrevocably grant to The Meggs Foundation II, Inc., ("The Meggs Foundation") and/or its subsidiaries, affiliates, representatives, assigns, licensees, and/or successors the right to use my story, my name, artwork, photographs, audiotapes, and/or letters that I provide of my child, my family, or myself in publications, slides, videotapes, motion pictures or on the internet, and in all forms and media including composite or modified representations for all purposes, including advertising, charitable solicitations, trade, or any commercial and/or charitable purpose throughout the world and in perpetuity. I waive the right to inspect or approve versions of any of the above listed used for publication or the written copy that may be used in connection with any images. The Meggs Foundation is permitted, although not obligated, to include my name as a credit in connection with any images. I understand any visual images, story, letters or recordings may be primarily used to inform families, volunteers, donors, the media and general public about The Meggs Foundation programs, services, fundraising efforts, or events. I gladly give this authorization to support the efforts of The Meggs Foundation. I understand this authorization shall continue unless terminated in writing by The Meggs Foundation. I release The Meggs Foundation and The Meggs Foundation's subsidiaries, affiliates, assigns, licensees, directors and successors from any claims that may arise regarding the use of my image, including any claims of defamation, invasion of privacy, or infringement of moral rights, rights of publicity, or copyright. The Meggs Foundation is not obligated to utilize any of the rights granted in this Agreement. Applicant's Name Date Signature

Today's Date:*

MonthDayYear

Applicant Signature:*

Please Print Name:*