FFOTX Application Form

GRANT APPLICATION DEADLINES

SUMMER
-Online application opens January 1 and closes July 31
-In-person 30-minute interviews for selected finalists will be in September

WINTER
-Online application opens August 1 and closes December 31
-In-person 30-minute for selected finalists will be in February

APPLICATION PROCESS
- Important note:
  Due to the number of applications we receive, we are unable to consider ANY incomplete applications.
- Required funds:
  It is required that our grant recipients have the funds available to cover costs outside of what the grant may cover.
- After application closes:
  FFOTX board members review all of the information and select the finalists based on availability of funds, applicant’s financials and unique situation.
- Next step:
  Finalists are contacted for an in-person interview with members of the board. Interviews last approximately 30 minutes and will be conducted at an Austin, TX location.
- Selected applicants:
  If you are selected, (within 1-2 weeks following the interview), we will run a credit/background check as the final step in the process and your grant will be ready for funding.
- IMPORTANT NOTE:
  The Fertility Foundation of Texas does not offer grants for oocyte (egg) or sperm cryopreservation, where the grant recipient has no immediate plans to attempt conception. This is due to a number of factors, including our limited funds and continued changes in technology and techniques surrounding retrieval and cryopreservation. We may reconsider this decision in the future and will update this website accordingly in the event of a change.

To ensure you qualify for the Fertility Foundation of Texas Grant, please review the following pre-qualifying criteria. If you meet ALL requirements below, you may proceed with the application process.
You are resident in one of the following Texas counties: Bastrop, Bell, Bexar, Blanco, Burnet, Caldwell, Comal, Coryell, Fayette, Gillespie, Gonzales, Guadalupe, Hays, Kendall, Lampasas, Lee, Llano, McLennan, Milam, Travis, Williamson.*
Your total household income is below $150,000 per year.*
You are uninsured for fertility treatment or your have exhausted your infertility coverage benefits. *
You have been evaluated by, and under the care of, a Board Certified Reproductive Endocrinologist who has diagnosed your cause of infertility and has prescribed a treatment plan; AND are receiving treatments at a SART member clinic (Society for Assisted Reproductive Technologies is an affiliated society to the American Society for Reproductive Medicine).*

This online application will include the following sections:
- Applicant(s) General Information
- Employment Information
- Personal Story
- Income, Expenses, and Assets
- Documentation Uploads
- Physician Information
- Agreement and Signature

HELPFUL TIPS FOR FILLING OUT THE ONLINE FORM

Save and Continue Later
- Click the Save button at the bottom of any page to save your progress.
- JotForm will email you a link to your saved submission.
- Use the link to return and complete the form at your convenience.
- You will need to create a JotForm account to use the save feature.
Required Documents to Upload Later in the Application
- Completed treating Physician Form (Click here to download).
- Copy of each applicant’s insurance cards (front and back).
- Copy of each applicant’s driver’s license.
- Two most recent Income Tax Returns (Form 1040; include Schedules C & E, if applicable), for each applicant if not a joint return.
- Two most recent pay stubs for each applicant.
- Two most current bank statements (from active accounts listed on the application) for each applicant if not a joint account.
QUESTIONS? Please contact us here.

APPLICANT #2
FULL NAME*

First NameLast Name
AGE*
DATE OF BIRTH*

MonthDayYear
Date
EMAIL*
example@example.com
PHONE*
Please enter a valid phone number.
PRESENT ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Own or rent? *
How many years at present address?*
FORMER ADDRESS (If residing at present address for less than two years)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Own or rent? How many years?
Is your mailing address different from present address?*
MAILING ADDRESS (if different from present address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HAVE YOU EVER BEEN CONVICTED OF A CRIME? If yes, please explain: *

APPLICANT #1
EMPLOYER NAME (or self-employed)*
EMPLOYER ADDRESS (enter NA if not applicable)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employment Information*

	Answer:
Position/Title:
Type of Business:
Years in this role:
Years employed in this line of work:
Current annual salary:
Previous year's salary:
If unemployed, please explain why:

APPLICANT #2
EMPLOYER NAME (or self-employed)*
EMPLOYER ADDRESS (enter NA if not applicable)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you have any children? If yes, please provide their ages and specify if from your current relationship (if applicable) or previous relationships.*
Please share a detailed personal story to help us learn more about you, your background(s), and your journey with infertility. Be open, be detailed, and let us get to know you and your story on a personal level.*

GROSS MONTHLY INCOME*

	Applicant #1	Applicant #2 (if applicable)
Employee Income
Overtime
Bonuses
Commissions
Dividends/Interest
Rental Income
Other

Your Total Combined Monthly Income: *

MONTHLY EXPENSES*

	Lender	Balance (if any)	Monthly Payment
Rent/Mortgage
Auto Payments
Auto/Home Insurance
Health Insurance
Groceries/Fuel
Electricity/Water/Gas/Trash
Phone
Internet
Other Monthly Expenses

Your Total Combined Monthly Expenses*
TOTAL MONTHLY INCOME MINUS MONTHLY EXPENSES*

ASSETS

	Name	Cash or Market Value
Bank, S&L or Credit Union
Bank, S&L or Credit Union
Bank, S&L or Credit Union
Stocks & Bonds
Life Insurance Net Cash Value

OTHER ASSETS

	Description	Cash or Market Value
401k/403b
IRA
Other Assets (please list)
Other Assets (please list)

YOUR TOTAL ASSETS AMOUNT:

Two most recent income tax returns (Form 1040; with Schedules C & E, if applicable) for each if not filed jointly*

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Two most recent pay stubs for each applicant *

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Copy of driver's license for each applicant*

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Two most current bank statements from active accounts listed on the application for each applicant if not a joint account*

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Any additional file uploads

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Please indicate financial resources you will receive to help you pay for your infertility treatment (if awarded the grant, you will be responsible for Physician fees as well as any costs that exceed the grant).*

InsuranceFamily/FriendsSavingsOther
Please explain in detail*

**The Fertility Foundation of Texas deems it necessary and relevant that the treating physician must be a Board Certified Reproductive Endocrinologist for the purpose of awarding grant monies because this subspecialty of the American Board of OB/GYN is specifically trained to diagnose and treat INFERTILITY. Many potential infertility patients are treated early and successfully by their OB/GYNs.
Name of Physician treating your Infertility*
Is this Physician a Board Certified Reproductive Endocrinologist ***

YesNo
Physician address and phone*
5. How long have you been under the care of this Physician?*
** CLICK HERE to download the required Treating Physician Form **
Upload the completed Treating Physican Form, signed by your physician. (Please note: Our grants do not cover physician fees)*

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Do you have health insurance coverage for infertility? *
If yes, who is your health insurance provider?*
If you DO have health insurance coverage for infertility, have you exhausted your coverage for infertility treatments?
Copy of applicants’ insurance cards front and back. By providing our signatures on this application, we hereby give Fertility Foundation of Texas permission to verify our insurance coverage.*

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We, the undersigned, understand that signing and submitting this application does not, in any way, guarantee that we will receive a Fertility Foundation of Texas (FFOTX) grant. We also understand that we are submitting personal health and financial information to be reviewed by FFOTX in making a determination as to our qualification for a grant. This information will be treated as CONFIDENTIAL by FFOTX and will be used for review purposes only. We understand that if we qualify for a FFOTX grant we will not receive any money directly and this money will be paid by the Fertility Foundation of Texas directly to the health provider, pharmacy, lab or other related parties on our behalf. None of the FFOTX grant money may be applied toward physician fees. We further understand that grant monies must be used within one year from the date of the award for the purposes for which it was requested, and that any unused monies will be held and reinvested by Fertility Foundation of Texas for future grant awards to help others in need. We will not receive any unused portions of the FFOTX grant at any time. We have read, understand and agree to all the terms and conditions described in this grant application.

I/WE DECLARE THIS APPLICATION TO BE THE FULL TRUTH TO THE BEST OF MY/OUR KNOWLEDGE.
I/We hereby agree to undergo background/credit checks.
By submitting this application, I/we acknowledge and agree that the submission constitutes electronic signature, affirming acceptance of the terms and conditions outlined in this application.
DATE*

MonthDayYear
Date
How did you are about us? Friend, Family, Social Media, News, Other?*
Should be Empty:

To ensure you qualify for the Fertility Foundation of Texas Grant, please review the following pre-qualifying criteria. If you meet ALL requirements below, you may proceed with the application process.

APPLICANT #1

APPLICANT #2

APPLICANT #1

APPLICANT #2