Smart PDF Form

Please list household resources (checking/savings, cash, vehicles, etc.):

Expenses:

Total Estimated Household Expenses:
Type of Assistance Requested
(Check all that apply and attach supporting bills)
Type of Assistance Requested

Transportation to/from treatmentMedical or prescription assistanceNutritional supplementsUtilities (electric, water, gas)Rent or mortgage assistanceOther
Amount Requested (if known):
File Upload

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Financial Hardship Explanation
Please briefly explain your current financial situation and need for assistance:

Required Documentation Checklist
Please attach copies of the following:

Proof of cancer diagnosis or treatmentProof of income (pay stubs, benefit letters, tax
return, etc.)Copies of bills for requested assistancePhoto IDProof of residency or treatment location
File Upload

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Applicant Certification & Authorization
I certify that the information provided on this application is true and complete to the best of my knowledge. I authorize the Louisiana Cancer Foundation and Cancer Foundation League to verify information provided and communicate with healthcare providers or agencies as needed to process this request.
Applicant Signature:

Clear
Printed Name:
Date:

MonthDayYear
Date
For Office Use Only
Date Application Received:

MonthDayYear
Date
Documentation Complete:

YesNo
Committee Review Date:

MonthDayYear
Date
Assistance Approved:

YesNo
Amount Approved: $
Notes:
Submit completed application and documentation to:
Louisiana Cancer Foundation / Cancer Foundation League
(Office use address, phone, and email to be inserted)

Louisiana Cancer Foundation For Research and Education