At this time Contractors For Kids can only assist families who reside on Long Island, NY Application for Assistance Δ 1Child Information2Contact Information3Income4Liabilities5Assistance and Verification6Authorization Required Documents A family letter explaining your financial situation and why you need financial assistance A letter from the child’s physician stating diagnosis and circumstances that might support your financial need Personal Tax Return: Pages 1 & 2 Schedule A Itemized Deduction (line 40 on page 2) Last two (2) months of bank statements Last two (2) paystubs or proof of income for both parents/legal guardians Birth certificate of the child or legal guardianship papers Copies of all bills you are requesting assistance with, along with supporting financial income documentation. **Additional information may be required Child InformationChild's Name(Required)Gender(Required) Male Female Child's Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child's Age(Required)Diagnosis(Required)Age at Diagnosis(Required)Primary Care Physician Name(Required)Physician Phone(Required)Social Worker(Required)Social Worker Phone(Required)Social Worker HospitalMedical Insurance(Required) Yes No Insurance Provider(Required)Medical Deductible(Required) Contact InformationParent/Legal Guardian 1(Required)Parent/Legal Guardian 2Address(Required)Where child resides Street Address Address Line 2 City State ZIP Phone Numbers(Required)At least one is required Home Phone Mobile Phone Alt Phone Home Phone(Required)Cell Phone(Required)Alt Phone(Required)Email(Required) How did you hear about Contractors For Kids?# Adults in Household (18+)(Required)# Dependents in Household(Required)As a result of my child’s illness, we are requesting assistance with the following bills: Company Name Statement Date Monthly Payment Past Due Copy of Bill Actions Edit Delete There are no Bills. Add Bill Maximum number of bills reached. IncomeGross Salary Parent/ Legal Guardian (1)(Required)Enter 0 if NoneGross Salary Parent/ Legal Guardian (2)(Required)Enter 0 if NoneFederal Aid Income(Required)Enter 0 if NoneSocial Security for All Children(Required)Enter 0 if NoneChild Support for All Children(Required)Enter 0 if NoneSection 8 Assistance(Required)Enter 0 if NoneSNAP Food Stamps(Required)Enter 0 if NoneHEAP Heat Assistance(Required)Enter 0 if NoneOther Income/Rental Income:(Required)Enter 0 if NoneAssetsChecking Account Balance(Required)Last 2 Checking Account Statements(Required)Include all details Drop files here or Select files Max. file size: 50 MB. Retirement Funds(Required)Enter 0 if NoneSavings Account Balance(Required)Enter 0 if NoneSavings Account Statement(Required) Drop files here or Select files Max. file size: 50 MB. Personal Residence Value(Required)Enter 0 if NoneCertificates of Deposit (CD’s)(Required)Enter 0 if NoneDo you have a Life Insurance Policy for child?(Required) Yes No Policy Type/Value(Required) LiabilitiesMortgage: Monthly PaymentMortgage: Total DueMortgage: Statement Date MM slash DD slash YYYY Mortgage: Due Date MM slash DD slash YYYY Home Equity Balance Monthly PaymentHome Equity Balance: Total DueHome Equity Balance Statement Date MM slash DD slash YYYY Home Equity: Due Date MM slash DD slash YYYY Rent: Monthly PaymentRent: Total DueRent: Statement Due Date MM slash DD slash YYYY Rent: Due Date MM slash DD slash YYYY Auto Insurance: Monthly PaymentAuto Insurance: Total DueAuto Insurance Statement Date MM slash DD slash YYYY Auto Insurance: Due Date MM slash DD slash YYYY Electric: Monthly PaymentElectric: Total DueElectric: Statement Date MM slash DD slash YYYY Electric: Due Date MM slash DD slash YYYY Cable: Monthly PaymentCable: Total DueCable: Statement Date MM slash DD slash YYYY Cable: Due Date MM slash DD slash YYYY Credit Card(s) Credit Card Name Monthly Payment Total Due Statement Due Date Actions Edit Delete There are no Credit Cards. Add Credit Card Maximum number of credit cards reached. Auto Loan(s) Auto Loan Name Monthly Payment Total Due Statement Due Date Actions Edit Delete There are no Auto Loans. Add Auto Loan Maximum number of auto loans reached. Personal Loans Personal Loan Name Monthly Payment Total Due Statement Due Date Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Other Expenses Expense Name Monthly Payment Total Due Statement Due Date Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. AssistanceIf you are receiving or have received assistance from any charity or fundraiser, please list themFamily/Friends, Church/Synagogue, Friends of Karen, Go Fund Me, A Mothers Kiss, Other Charity Amount Received Date Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Signature and VerificationVerification(Required) I hereby certify that, to the best of my knowledge, the information provided is accurate and complete. Parent or Legal Guardian Name(Required)Parent or Legal Guardian Signature(Required) Agent Proxy Authorization - Medical Information(Required)Please be advised that I have designated Debbie O’Rourke, Noel Gorton-RN, Eric Seigneuray and Randi Gorton of CONTRACTORS FOR KIDS, INC. (CFK) a New York not for profit corporation and charitable organization under IRS 501 (c)(3), to represent, advise and assist the undersigned (Parent/Legal Guardian Name - SEE BELOW) in my application to CFK for financial assistance due to the medical condition of my child. This proxy shall take effect immediately without any further authorization or notice to me to facilitate my application. My agent(s) herein named shall also have the authority to execute any and all releases and authorizations, and to request, communicate and or to disclose and related medical information and patient records of the undersigned in the same manner as the designated individual(s) involved with my care and as may be the subject of or required by the Health Insurance Portability and Accountability Act (HIPAA). Please share all pertinent information of the undersigned related to medical information and records, insurance coverage and appeals with them in order to expedite representation. If additional information is required, please contact any of the above designates at 631-617-5152 or write or email them at [email protected] or at CONTRACTORS FOR KIDS, INC. located at 20 Peachtree Court, Suite 103L , Holbrook, NY 11741. I agree to the Agent Proxy Authorization - Medical InformationParent or Legal Guardian Name(Required)for Agent Proxy Authorization - Medical InformationParent or Legal Guardian Signature(Required)Agent Proxy Authorization - Medical InformationNameThis field is for validation purposes and should be left unchanged.
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