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Apply for Assistance
We are grateful to use our resources to help those in need. Please fill out the form below to be considered for grant funding.
APPLICANT INFORMATION
Full name
*
Address line 1
*
Address line 2
*
City / State / province
*
Postal / zip code
*
Home Phone Number
*
Cell Phone Number
*
Email Address
*
Confirm Email Address
*
Relationship to the cancer patient that financial support is being applied for?
*
PATIENT INFORMATION
(If not the person applying)
Patient's First Name
*
Patient's Last Name
*
Patient's Date of Birth
*
Gender
*
Ethnicity
*
Marital Status
*
Religion
*
Language
*
Place of birth
*
HEALTH INSURANCE INFORMATION
Does the patient have health insurance?
*
Yes
No
If yes, please note the type of insurance (select all that apply)
Private Insurance
Medicare
Medigap
Other (if 'Other' please specify here)
Medicaid
Medicare Plus
Veteran's Administration Benefits
Other write
FINANCIAL ASSISTANCE NEEDS
I need financial assistance to offset the following cancer-related expenses: (check all that apply)
Basic Living Expenses (Mortgage/Rent/Utilities/Food)
Transportation
Lymphedema Supplies
Personal Items (Wig Services, Prosthesis Bras, Hats)
Pain Medications
Other (if 'Other' please specify here)
Home Care (Nursing Services & Cleaning)
Child Care
Other write
FINANCIAL INFORMATION
Is the patient employed?
Yes
No
Number of people in the household
*
Please list members of the household (including age/relationship to patient)
I need financial assistance to offset the following cancer-related expenses: (check all that apply)
Salary
Social Security Disability
Public Assistance
Short Term Disability
SSI
Social Security (Retirement)
Unemployment
Family/Friends Provide Support
Pension
Other (if 'Other' please specify here)
Other write
Total Annual Family Income
*
FAMILY ASSETS
Please include info from all household members
Checking/Money Market Accounts
*
$
Savings/CD
*
$
IRA/403B/401K
*
$
Stock & 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.
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