YOU CAN SAVE A LIFE, DONATE TODAY! APPLY FOR ASSISTANCE APPLICATION FOR GRANT ASSISTANCE Thank you for your interest. We are currently at capacity and will resume taking applications as soon as possible. supporting our local community: We are currently funding applications for patients in our local service area (Washington DC, Maryland, Virginia and New Jersey) FIRST NAME LAST NAME GRANTEE FIRST NAME GRANTEE LAST NAME ADDRESS LINE 1 ADDRESS LINE 2 CITY STATE District of Columbia Virginia Maryland New Jersey POSTAL/ZIP CODE HOME PHONE NUMBER CELL PHONE NUMBER EMAIL ADDRESS CONFIRM EMAIL ADDRESS PATIENT'S FIRST NAME PATIENT'S LAST NAME PATIENT'S DATE OF BIRTH GENDER ETHNICITY MARITAL STATUS RELIGION LANGUAGE PLACE OF BIRTH DOES THE PATIENT HAVE HEALTH INSURANCE Yes No IF YES, PLEASE NOTE THE TYPE OF INSURANCE (SELECT ALL THAT APPLY) Private Insurance Medicaid Medicare Medicare Plus Medigap Veteran's Administration Benefits Other (If 'Other', Please specify here) I NEED FINANCIAL ASSISTANCE TO OFFSET THE FOLLOWING CANCER-RELATED EXPENSES: (CHECK ALL THAT APPLY) Basic Living Expenses (Mortgage/Rent/Utilities/Food) Personal Items (Wig Services, Prosthesis Bras, Hats) Home Care (Nursing Services & Cleaning) Transportation Pain Medications Child Care Lymphedema Supplies Other IS THE PATIENT EMPLOYED? Yes No NUMBER OF PEOPLE IN HOUSEHOLD PLEASE LIST MEMBERS OF THE HOUSEHOLD (INCLUDING AGE/RELATIONSHIP TO PATIENT) CHECKING/MONEY MARKET ACCOUNTS SAVINGS/CD IRA/403B/401K STOCKS & BONDS OTHER TOTAL FAMILY ASSETS PLEASE UPLOAD A COPY OF A LETTER FROM YOUR MEDICAL PROVIDER VERIFYING YOUR CURRENT BREAST CANCER TREATMENT. PROVIDING THIS INFORMATION WITH THE SUBMISSION OF YOUR APPLICATION WILL ASSIST IN EXPEDITING THE PROCESSING OF YOUR APPLICATION. INFORMATION WILL BE REVIEWED BY THE DONNA M. SAUNDERS FOUNDATION AND WE WILL CONTACT THE APPLICANT. ALL INFORMATION IS CONFIDENTIAL AND FOR USE BY THE DONNA M. SAUNDERS FOUNDATION ONLY. Submit
