WHW Financial Assistance Application

WHW Financial Assistance Application

Complete the application with your household, medical, and financial details, then upload the required documents to submit for review.
Applicant Information
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
ZIP Code
County
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Method of Contact
Medical Information
Type of Cancer
Date Diagnosed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Cancer Stage
Treatment Facility
Treating Physician
Current Treatment

Other
Expected Treatment End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Assistance Request
Amount of Assistance Requested
Describe the bills or expenses needing assistance
Payee Name (company, landlord, mortgage company, pharmacy, or service provider)
Account Number (if applicable)
Payment Due Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Supporting Documents
Government-issued Photo ID

Cancelof
Proof of Cancer Diagnosis

Cancelof
Copy of Current Bill(s) Requesting Assistance

Cancelof
Any Additional Supporting Documents

Cancelof
Certification & Signature
Acknowledgement
Electronic Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Agreement to Terms
Confidentiality Notice: All information submitted through this application will be treated as confidential and used solely to determine eligibility for assistance and to administer the Women Helping Women Financial Assistance Program.
Should be Empty:

WHW Financial Assistance Application

Applicant Information

Medical Information

Assistance Request

Supporting Documents

Certification & Signature