DMSF Application For Assistance

Application for Financial Assistance

APPLICANT INFORMATION

Applicant's First Name

*

Applicant's Last Name

*

Street Address

*

Street Address 2

*

City

State

*

Postal Code

*

Home Phone Number

Cell Phone Number

Email Address

Confirm Email Address

Relationship to the cancer patient that financial support is being applied for?

*

CANCER PATIENT INFORMATION (If not the person applying)

Patient's First Name

*

Patient's Last Name

*

Patient's Date of Birth (MM/DD/YYYY)

*

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
Medicaid
Medicare
Medicare plus
Medigap
Veteran's Administration Benefits
Other

If "other", please specify

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
Home Care
(Nursing Services. & Cleaning)
Pain Medications
Lymphedema Supplies
Child Care
Personal Items
(Wig Services, Prosthesis Bras, Hats)
Other

If "other", please specify

FINANCIAL INFORMATION

Is the patient employed?

Yes No

Number of people in the household:

*

Please list members of the household
(include age/relationship to patient)

Household Income (check all that apply):

Salary
Public Assistance
Pension
Short Term Disability
Social Security (Retirement)
Unemployment
Social Security Disability
Family / Friends Provide Support
SSI
Other

If "other", please specify

Total Annual Family Income

*

FAMILY ASSETS (Please include info from all household members)

Checking/Money Market Accounts:

Savings/CD:

IRA/403B/401K:

Stocks & Bonds:

Other:

Total Family Assets:

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. Verification of medical diagnosis may be requested to complete the application process. A request for such information will be provided as necessary.

Security Code
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*