Application for Assistance

1Child Information

2Contact Information

3Income

4Liabilities

5Assistance and Verification

6Authorization

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 Information

Child's Name(Required)

Gender(Required)

Male

Female

Child's Date of Birth(Required)

Child'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 Hospital

Medical Insurance(Required)

Yes

Insurance Provider(Required)

Medical Deductible(Required)

Liabilities

Mortgage: Monthly Payment

Mortgage: Total Due

Mortgage: Statement Date

Mortgage: Due Date

Home Equity Balance Monthly Payment

Home Equity Balance: Total Due

Home Equity Balance Statement Date

Home Equity: Due Date

Rent: Monthly Payment

Rent: Total Due

Rent: Statement Due Date

Rent: Due Date

Auto Insurance: Monthly Payment

Auto Insurance: Total Due

Auto Insurance Statement Date

Auto Insurance: Due Date

Electric: Monthly Payment

Electric: Total Due

Electric: Statement Date

Electric: Due Date

Cable: Monthly Payment

Cable: Total Due

Cable: Statement Date

Cable: Due Date

Credit Card(s)

Credit Card Name	Monthly Payment	Total Due	Statement Due Date	Actions

There are no Credit Cards.

Auto Loan(s)

Auto Loan Name	Monthly Payment	Total Due	Statement Due Date	Actions

There are no Auto Loans.

Personal Loans

Personal Loan Name	Monthly Payment	Total Due	Statement Due Date	Actions

There are no Entries.

Other Expenses

Expense Name	Monthly Payment	Total Due	Statement Due Date	Actions

There are no Entries.

Charity	Amount Received	Date	Actions

There are no Entries.

Parent or Legal Guardian Name(Required)

for Agent Proxy Authorization - Medical Information

Parent or Legal Guardian Signature(Required)

Agent Proxy Authorization - Medical Information

Comments

This field is for validation purposes and should be left unchanged.

Company Name	Statement Date	Monthly Payment	Past Due	Copy of Bill	Actions

There are no Bills.