Gratitude and Grace Foundation Financial Assistance Funds Application

Gratitude and Grace Foundation Financial Assistance Funds Application
The Financial Assistance Funds application was created to offer financial aid to organ transplant recipients, aiming to alleviate their stress. The Gratitude and Grace Foundation provides various forms of support, including food assistance, utility bill assistance, gas/transportation, and co-pay/medication expenses. At present, this program is available to individuals who are current residents of Arizona.

Our mission is to provide essential financial support and resources to patients and their families as they navigate the challenging journey of recovering from organ failure or substance abuse.

We are dedicated to bridging the gap between these two critical aspects, ensuring that families receive the necessary assistance during this journey.

Through our dedicated efforts, we strive to empower individuals, alleviate their financial burden, and enhance their chances of successful recovery.
Recipients Name*

First NameLast Name
Birth Date *

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
By entering an email address, Gratitude and Grace Foundation has permission to add recipient to our email list to receive monthly newsletter.
Recipients Gender Identification?*

MaleFemaleOther
How much do the members of your household have in cash or in a bank account?*

Less than $1000$1000 - $2500$2500 - $5000$5000 - $10,000More than $10,000
What is the total amount of income you expect your household to receive this month? *
What is your current monthly rent/mortgage payment?*
Have you or anyone in your household received or do you expect to receive Food Assistance benefits from any other county or any other state this month?*

YesNo
Are you currently employed?*

YesNo
Are you in need of assistance within the next 48 hours?*

YesNo
What type of assistance are you applying for?*

GroceriesUtility PaymentGas/ TransportationMedication/Co-Pay
Has recipient received a solid organ transplant?*

YesNoOn the transplant list for organ
Date of transplant

MonthDayYear
Date
What organ are you currently on the transplant list for?*

LiverKidneyHeartLungIntestinePancreasOther
Which transplant facility are you working with?*

Banner UMC-PhoenixBanner UMC-TucsonDignity HealthMayo ClinicPhoenix Children's HospitalOther
Household Information*
Who is the insurance provider?*
Why does the recipient need financial assistance?*
Who is the insurance provider?*
Does the patient have insurance?*
Consent

I authorize and consent to collect and share all of my records, data, and information.
Please note that one of our support team members will reach out to you regarding your application within the next 48 hours.

By submitting this application, I consent to the review of the information provided. I understand that additional information might be required and agree to comply to ensure the application decision can be made in a timely manner. I understand that my information will not be sold or shared for commercial purposes. I certify that the information and items submitted in this application are accurate and completed to the best of my knowledge.

By clicking submit I agree to the above statements.
Signature*

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Gratitude and Grace Foundation Financial Assistance Funds Application

Consent