Treatment Support Grant Application

Only completed application packets will be accepted.

Please enter all that apply and upload copies of documentation. You MUST Report Income for ALL Members of Your Household!

Fill in the amount of each monthly bill. Copies of bills for which financial assistance is requested, must be uploaded.

Please enter all that apply.

[1] Application must be completed in its entirety, to include upload of required documentation. [2] Documentation must be properly uploaded once. Documents will not be received ‘piece meal.’ [3] Incomplete applications will NOT make their way to Grants Committee for review. [4] Grants Committee Members are confidential. [5] Must allow up to thirty (30) days for application review. Payments may take up to 30 days to process. [6] Applications will be reviewed without bias based on age, race, county of residence, or treating physician(s). [7] The basis of determination by the Grants Committee will be available, in writing, upon request. [8] Applications will remain open for no greater than thirty (30) days from date of receipt.

I certify that all the information I have provided is true, complete and correct. I expressly authorize, without reservation, the Hooked on Hope Breast Cancer Treatment Support Grants Program and its advisors or representatives to contact and obtain information in order to verify the accuracy of information provided by me in this application. I understand that I will be required to provide backup documentation to Hooked on Hope or its representatives in order to verify the information provided herein. I understand that any information that may not be verified, is incomplete, or is misrepresented in any respect will be sufficient cause to eliminate me from consideration for financial assistance and will result in the denial of this application. Do not sign until you have read the above application statement. I certify that I have read, fully understand and accept all terms of the foregoing application statement: I understand that my application may not be submitted to the Hooked on Hope Grants Committee for consideration unless it is completed in its entirety and required/requested backup documentation has been provided.

Please upload supporting documentation for Proof of Treatment & Section 2: Financial Information.