APPLICATION FOR FINANCIAL ASSISTANCE
(Applications must be completed in full and accompanied by mandatory supporting documents and check-list in ordered to be accepted)
Date of Application________________
TELL US ABOUT YOURSELF
First Name: ________________________ Last Name_____________________________
Address: _____________________________________ Apt/Suite/Unit#_____________
City:_________________ Province:______________ Postal Code: __________________
E-mail Address:___________________________________________________________
Home Phone #:( )_____________ Bus Phone #:( )__________ Fax #: ( )___________
Canadian Citizen: YES___ NO ___ Landed Immigrant: YES__ NO__ OTHER (explain):______
Marital Status________ # of Dependents and ages:________________________________
# of people in household (total, including dependants and non-dependants) ________
Relation:_________________________________________________
HELP US UNDERSTAND YOUR DIAGNOSIS
Diagnosed with Breast Cancer on (date) ____________________ Type: ________________
Where are you being treated? (Name of facility/hospital): ___________________________
Are you still receiving chemotherapy or radiation therapy?___ YES ____ NO
If no, please let us know your last date of treatment for above:________________________
Treatment received to date: _________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Additional Treatment required: ________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Family Doctor: ___________________________Phone Number: ( ) ________________
Oncologist’s Name: _______________________ Phone Number: ( ) _________________
Social Worker Name: ______________________ Phone Number: ( ) ________________
PLEASE HELP US UNDERSTAND YOUR FINANCIAL SITUATION
Are you self-employed? YES / NO Occupation: ___________ Are you Retired? YES / NO
Are you currently working full or Part-time? YES / NO If No, Last day of work: __________
Your net monthly income $:_____________ Spouses monthly net income: $_____________
Total Net Family Monthly Income: $_____________
Monthly Mortgage/Rental Payment $__________
Groceries/Food $__________
Cable/phone/internet $__________
Utilities (Hydro/Water/gas) $__________
Car payment/loan $__________
Other Loan payment(s) $__________
Insurance $__________
Other $__________ Total Expenses: $________________
Total Income $_____________________
Less Total Expenses $_____________________
Net surplus/loss $_____________________
Are you receiving financial aid from the government or other sources? YES____ NO____
Please include all other income into home, such as disability income, spouse’s/partner’s income, rental income, alimony, child support etc. Please provide description of all sources of income and amounts you receive monthly. Feel free to give any other details or comments you feel are important. Please also explain if “other” was filled in: _______________________________________________________________________
_______________________________________________________________________
YOUR MEDICAL SUPPORT TEAM
(Please have your doctor/Nurse/Social Worker, Etc. Fill out this section)
Medical Diagnosis & Comments_________________________________________________
______________________________________________________________________________________________________________________________________________
I have read and reviewed this complete application and to the best of my knowledge can confirm that this applicant is currently undergoing Breast Cancer treatment and is in financial need for assistance.
__________________________________
Signature of medical or social expert
__________________________________ Contact #: ( ) ________________________
Please print your name & position clearly
AUTOGRAPH (Applicant must sign and authorize release to confidential information)
I certify that the above information is accurate. I also understand that this information is to be used by the Kelly Shires Breast Cancer Snow Run/Foundation for the sole purpose of assisting me financially
______________________________________________________
(Signature of applicant)
PLEASE HELP US TO HELP OTHERS
How did you find out about our organization? ______________________________________
How could we be more helpful? ________________________________________________
Other Comments or suggestions? ______________________________________________
Kelly Shires Breast Cancer Foundation
523 Elizabeth Street, Suite 101
Midland, Ontario L4R 2A2
TOLL FREE 1-877-436-6467
E-mail:info@breastcancersnowrun.org
PLEASE TELL US HOW WE CAN ASSIST YOU?
Please let us know what you would like us to be able to help you with financially, our goal is to make life less stressful financially so you can focus on your recovery. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________
Please itemize your request (remember to include ORIGINAL receipts where applicable, receipts that have multiple items on them need to have items highlighted that you wish financial aid with)
Item #1______________________________ $______________
Item #2______________________________ $______________
Item #3______________________________ $______________
Item #4______________________________ $______________
Item #5______________________________ $______________
Item #6______________________________ $______________
Item #7______________________________ $______________
Item #7______________________________ $______________
Item #8______________________________ $______________
Item #9______________________________ $______________
Total funds requested: $______________
Note: Maximum that will be approved with each request is $1000.00, please note caps on certain items on the document listed as “criteria for assistance”. Balances will NOT be carried forward to future requests. (some exceptions may apply)
MANDATORY CHECK LIST
(to be submitted with application)
We understand that life is difficult and would like to make this application process as easy as possible for applicants. Therefore, it is important to note that the documentation requested below is MANDITORY in order for a request to be considered. It is important to note that an application is considered to be incomplete and will not be submitted to the Approval Committee if ALL pertinent documentation is not included.
In order to establish financial need, applicants MUST:
üProvide medical report supporting diagnosis
üProvide current income tax notice of assessment for yourself and spouse/partner
üProvide current income tax return
üProvide Proof of citizenship/approved landed immigrant status
üProvide proof of any/all income such as disability, Ontario works, etc.
üProvide ORIGINAL receipts/estimates
üProvide rent or mortgage statement, if applicable
üprovide Record of Employment (ROE), if applicable
üSign the application and obtain signature from their medical professional
üEach application MUST included an item directly related to breast cancer diagnosis and/or treatment
ü
All personal information is protected under the Canadian Privacy Act. (Kindly note if requested documentation is not included it will only delay any financial assistance that could possibly be provided).
CHECKLIST
THE FOLLOWING & CHECKLIST MUST BE INCLUDED WITH YOUR APPLICATION:
____ Medical Report supporting diagnosis
____ Current Notice of Assessment for yourself and your spouse if applicable
____ Current Income tax return for yourself
____ Proof of Citizenship or landed immigrant status/ Birth Certificate
____ Proof of other funding received (EI, ODSP, Ontario Works, etc)
____ Receipts/Estimates (ORIGINALS)
____ Mortgage/Rent Statement
____ ROE (Record of Employment), if applicable
____ Application signed by Medical or Social Expert
____ Application signed by applicant
PLEASE NOTE THAT ALL 6 PAGES OF THE APPLICATION MUST BE COMPLETED IN FULL AND MAILED TO THE ADDRESS BELOW IN ORDER TO BE CONSIDERED ADMISSABLE BEFORE THE COMMITTEE.
KELLY SHIRES BREAST CANCER FOUNDATION
523 ELIZABETH STREET
SUITE #101
MIDLAND, ONTARIO
L4R 2A2
“Offering Financial Assistance”
Questions regarding this application can be sent to info@breastcancersnowrun.org