Beneficiary Application Intake Form

Beneficiary Application Intake Form

Apply for financial assistance due to a critical medical diagnosis. Please complete all relevant sections. All information is confidential and will be used solely for eligibility evaluation.

Applicant Information
Name of individual completing this form*

First NameLast Name
Email address of applicant*
example@example.com
Phone number of applicant*
Please enter a valid phone number.
Relationship to the individual with the critical medical diagnosis (e.g. child, spouse, friend)*
Are you submitting this form for another individual and, is the individual aware that you are submitting this application on their behalf?*

YesNo
If you are submitting this form for another individual: Is the individual aware that you are submitting this application on their behalf?*

YesNo

Individual with Critical Medical Diagnosis
Full name of individual with diagnosis*

First NameLast Name
Date of birth*

MonthDayYear
Date
Mailing address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Is the individual a resident of Hillsborough?*

YesNo
Is the individual willing to be a beneficiary of a fundraising event where their name would be disclosed?*

YesNo

Medical Hardship Information
Medical diagnosis*
Please provide a brief description of why you are seeking financial assistance*
Are you currently receiving financial assistance?*

YesNo
If yes, please describe the financial assistance you are currently receiving
Describe the medical expenses for which you are requesting assistance, including estimated amounts not covered by insurance*
Attach supporting documentation (e.g., EOBS, deductible statements, denial letters, unpaid invoices). Please redact any sensitive information such as policy numbers or social security numbers.

Cancelof

Financial Need Summary
You may be asked to provide one of the following documents for income verification if further verification is needed:
• Most recent tax return
• Recent pay stub(s)
• Social Security, pension, or disability income statement

General Household Members*

	Number of Adults	Number of Children/Dependents	Total Household Members
Household Members

Consent and Declaration
I, {q3_fullname1}declare that the information provided in this application is true and accurate to the best of my knowledge.

Providing false or incomplete information may result in rejection of my application.

Hearts of Hope Hillsborough Corp. may verify the information provided and request additional documentation.

All information will remain confidential and used solely to evaluate my eligibility for assistance.
I agree to:*

Meet with a Hearts of Hope Hillsborough representative to review my application.If selected to be a beneficiary, refrain from disclosing, discussing, or communicating any details regarding funds received (including amount, source, or terms) without written consent from Hearts of Hope Hillsborough Corp.
Signature of applicant*

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Date signed*

MonthDayYear
Date
To protect your privacy, we kindly ask that this information not be sent by email. You may complete this form using the encrypted platform. If you prefer not to use the online form, you're welcome to print the form and hand it directly to a Hearts of Hope Hillsborough Corp committeem member.
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