Treatment Support Grants Application

Section 1: Patient Information

Funding priority will be given to employed individuals temporarily unable to work due to breast cancer treatment.

Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone(Required)

Work Phone

Home Phone

Email(Required)

Date of Birth(Required)

Marital Status(Required)

Last 4 Numbers of Social Security Number(Required)

Who Referred you to Hooked on Hope?

Source of Income & General Information

Applicant must upload proof of income with application for consideration (i.e., pay stub, letter from employer, Social Security Letter, Disability Letter).

Primary Source of Income(Required)

Employed(Required)

Yes

Were you employed at the time of your breast cancer diagnosis?(Required)

Yes

Employment Status/Source of Income BEFORE your breast cancer diagnosis:(Required)

Employer Name before diagnosis or N/A:(Required)

Was this SSI Permanent disability related to your breast cancer diagnosis?(Required)

FMLA/Sick leave date effective (if applicable):

SSI/Permanent Disability date effective (if applicable):

CURRENT Employment Status/Source of Income:(Required)

Current Employer Name (If applicable):

FMLA/Sick leave date effective (if applicable):

SSI/Permanent Disability date effective (if applicable):

If not currently employed, what is the last date you worked:(Required)

If not currently employed, what is your source of income:(Required)

Health Insurance

Are you covered by Health Insurance?(Required)

Yes

If Yes,

If no, please explain why?

Breast Cancer Treatment

Applicant must upload proof currently undergoing treatment with application for consideration (i.e., note of doctor, pathology report).

Date Diagnosed:(Required)

Are you still in treatment?(Required)

Yes

Other

Date your Breast Cancer Treatment began(Required)

Date your Breast Cancer Treatment ended (If applicable)

Surgery/Surgeries Start & End Dates: (If applicable)

Name of Surgeon(s)/Hospital: (If applicable)

Chemotherapy Start Date (If applicable)

Chemotherapy End Date (If applicable)

Name of Medical Oncologist/Clinic: (If applicable)

Radiation Therapy Start Date (If applicable)

Radiation Therapy End Date (If applicable)

Name of Radiation Oncologist/Clinic: (If applicable)

Lymphedema Therapy Start Date (If applicable)

Lymphedema Therapy End Date (If applicable)

Name of Therapy Program: (If applicable)

Other Therapy or Treatment Details: (If applicable)

Treating Physicians:

Surgery:

Reconstructive Surgery:

Chemo Therapy:

Radiation:

Section 2: Financial Information

Applicant must upload 3 months most recent bank statements with application for consideration.

Number of adults living in your household(Required)

Please enter a number from 0 to 10.

Number of working adults in your houshold(Required)

Number of children (Under 18) living in your household(Required)

Please enter a number from 0 to 10.

Household Monthly Income

Please enter all that apply and upload copies of documentation. You MUST Report Income for ALL Members of Your Household! Please enter 0 if not applicable.

Employment Wages (NET Income after Taxes)(Required)

Social Security (retirement)(Required)

SSI / SSDI (Disability)(Required)

Pension / Retirement(Required)

Unemployment(Required)

Short Term Disability / Sick Leave(Required)

Alimony or Childcare(Required)

Other Income(Required)

Household Monthly Expenses

Fill in the amount of each monthly bill. Grant Chair will contact patient to review bills. Please enter 0 if not applicable.

Rent / Mortgage(Required)

Phone(s)(Required)

Electric / Gas(Required)

Water / Sewer(Required)

Food(Required)

Auto Payment(Required)

Auto Fuel(Required)

Auto Insurance(Required)

Property Insurance(Required)

Property Tax(Required)

Life Insurance(Required)

Health Insurance(Required)

Alimony(Required)

Child Support(Required)

Co-Pays for Office or Treatment Visits (for breast cancer treatment)(Required)

Prescriptions (for breast cancer treatment)(Required)

Other Expenses(Required)

Household Assets

Please enter all that apply.

Amount in Checking Account(Required)

Amount in Savings or Money Market(Required)

Cash On Hand(Required)

Value of 401K, Retirement Funds, Stocks, Bonds, etc.(Required)

Do you or your spouse/partner own property other that your Primary Residence?

Yes

Do you or your spouse/partner/family own a business?

Yes

Additional Information

Is there any other information you wish to share with the Grants Committee?(Required)

Important Notifications

[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.

Release and Terms Of Agreement

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.

Electronic Signature(Required)

Please enter full legal name

Date(Required)

Supporting Documentation

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

File

Max. file size: 256 MB.

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