Section 1: Patient Information
Funding priority will be given to employed individuals temporarily unable to work due to breast cancer treatment.
First Middle Last Address (Required) Marital Status (Required) Married Single Devorced Widowed Domestic Partnership 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).
Employed (Required) Were you employed at the time of your breast cancer diagnosis? (Required) Employment Status/Source of Income BEFORE your breast cancer diagnosis: (Required) CURRENT Employment Status/Source of Income: (Required) Health Insurance Are you covered by Health Insurance? (Required) If Yes, Breast Cancer Treatment
Applicant must upload proof currently undergoing treatment with application for consideration (i.e., note of doctor, pathology report).
Are you still in treatment? (Required) Surgery/Surgeries Start & End Dates: (If applicable) Other Therapy or Treatment Details: (If applicable) Treating Physicians: 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) Number of children (Under 18) living in your household (Required) 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.
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.
Please enter all that apply.
Do you or your spouse/partner own property other that your Primary Residence? Do you or your spouse/partner/family own a business? Additional Information Is there any other information you wish to share with the Grants Committee? (Required) Important Notifications
 Application must be completed in its entirety, to include upload of required documentation.  Documentation must be properly uploaded once. Documents will not be received ‘piece meal.’  Incomplete applications will NOT make their way to Grants Committee for review.  Grants Committee Members are confidential.  Must allow up to thirty (30) days for application review. Payments may take up to 30 days to process.  Applications will be reviewed without bias based on age, race, county of residence, or treating physician(s).  The basis of determination by the Grants Committee will be available, in writing, upon request.  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) Reset signature Signature locked. Reset to sign again
Please enter full legal name
Consent I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms Of Acceptance.. Supporting Documentation
Please upload supporting documentation for Proof of Treatment & Section 2: Financial Information.