Unpaid Christian Science Nursing Invoices

The DOMINION FOUNDATION
for Christian Science Nursing, Inc.

Application for financial assistance with
Unpaid Christian Science Nursing Invoices

We ask that you please apply to the National Fund for Christian Science Nursing at nfcsn.org. before applying to the Dominion Foundation. Have you applied to the National Fund?*

YesNo

We provide grants for unpaid Christian Science nursing invoices. Do you have unpaid invoices after receiving Christian Science nursing care in the home?*

YesNo

If you answered “Yes” to these questions, you may qualify for a grant. Please complete the application fully to enable us to process your request. All information you provide will be kept strictly confidential.

Name*

PrefixFirst NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Email

example@example.com

Phone Number*

Monthly Income*

	$
Wage/Salary
Social Security
Annuity
Dividends/Interest

Total Monthly Income

Assets*

	$
Checking Account
Savings account
Real estate—Home
Real estate—Other
Stocks/Bonds
Insurance
Other Assets

Total Assets

Monthly Expenses*

	$
Mortgage/Rent
Utilities
Insurance
Other expenses

Total Monthly Expenses

Liabilities*

	$
Mortgage
Debts
Other Liabilities

Total Liabilities

After insurance benefits have been fully utilized, The Dominion Foundation for Christian Science Nursing, Inc., will consider payment of the remaining expenses for Christian Science home nursing care. This includes insurance deductibles. Do you have health or disability insurance or other sources of financial assistance that would cover part of the costs of the Christian Science nursing?*

YesNo

Where else have you applied for funds? Please indicate where you have applied. *

May we have permission to contact other funding organizations that you have applied to?*

YesNo

Estimated financial assistance needed $*

Please submit unpaid invoices from the Christian Science nurse with this application or mail them to The Dominion Foundation for Christian Science Nursing, Inc. at the address on page 1. Christian Science nursing invoices should include hourly or daily charges, travel expenses, and supplies and equipment needed to provide care. Valid receipts are required for travel expenses, supplies, and equipment. Invoices should also list all payments from other sources and any patient contribution.

I will mail in my unpaid Christian Science nurses invoices with this application.I will email my unpaid Christian Science nurses invoices separately to applications@dominionfoundation.netI will upload my unpaid Christian Science nurses invoices on this form

Invoice Upload 1

Browse Files

Please upload your invoices from your computer or mobile device

Invoice Upload 2

Browse Files

Please upload your invoices from your computer or mobile device

Invoice Upload 3

Browse Files

Please upload your invoices from your computer or mobile device

By providing my signature below, I affirm that all information provided on this form is accurate.

Date*

Date

Applications and invoices are reviewed on a monthly basis by the Trustees. You will be notified shortly after
the monthly meeting.

Applicants receiving grants will be mailed a check made out to the Christian Science nurse. All communication regarding the grant will be with the applicant, not the Christian Science nurse.

Signature

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