APPLICATION FOR CHARITABLE ASSISTANCE

The Mountain Life Charitable Foundation (the Organization) provides charitable assistance grants to the residents of our hometown, Island Park, Idaho. Funding is limited and may not be available for every applicant. Our grants are intended for those without means for necessities, those facing extraordinary circumstances or otherwise to help our neighbors in need.

No assistance is guaranteed, and the Organization reserves the right to deny any applicant in the Organization’s sole and absolute discretion.

This application will help us evaluate your situation, or the situation of the person you nominate. Below are the guidelines we consider when evaluating an application. The Organization will use the information provided on the application to determine if the request fits inside our parameters and determine what aid we can provide. Further discussion with the intended beneficiary may be necessary to determine what aid may be provided, and the Organization may request consent to work directly with providers and/or merchants to negotiate for the most benefits possible.

GUIDELINES

• Grants will not exceed $2,000 for a beneficiary in any given year

• Intended beneficiary must be an Island Park resident

• Aid from the organization could meaningfully impact the life of the intended beneficiary

AREAS OF ASSISTANCE

Medical Need: The intended beneficiary requires surgery, treatment or a procedure to keep them alive or prevent significant deterioration of their health and they are required to pay a substantial amount of the cost.

Necessities: The intended beneficiary is of modest income and has trouble providing for basic needs such as food, clothes, medications or other basic needs.

Extraordinary Circumstances: The intended beneficiary is facing an abnormal circumstance that is causing the need, i.e., death of a spouse, child or other household member, damage or loss from fire or other casualty, or other temporary need caused by unfortunate circumstance.

School Aged Children: The intended beneficiary has a child or children under the age of eighteen (18) and needs help providing for school supplies, food, medication, after school programs or otherwise to assist with the needs of raising the child/children.

President: Patty Laritz-Bithell

PO Box 441

Island Park, ID 83429

(208) 860-4846

Info@mountainlifecharity.org

Beneficiary Name*

First NameLast Name

Beneficiary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Beneficiary Email*

example@example.com

Beneficiary Phone Number*

Please enter a valid phone number.

Please describe the need for assistance. State the financial impact of the need with specificity sowe can determine what level of assistance being requested and determine our ability to provide it.Please, be general regarding any medical information but provide enough detail for us todetermine the condition’s effect on the intended beneficiary.*

If you are both the intended beneficiary and the applicant, may we use your name in fundraisingefforts if we host an event to help provide you assistance?*

Yes I am the beneficiaryYes I am NOT the beneficiaryNo I am the beneficiaryNo I am NOT the beneficiary

Signature*

Today's Date*

Date

Applicant detail if not intended beneficiary:*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com