revised on May 6, 2011
APPLICATION FOR FINANCIAL ASSISTANCE
(request MUST be completed in full and ALL pertaining documents included so as to have the file submitted to the approval committee)
Date of Application________________________
TELL US ABOUT YOURSELF
First Name: _______________________________ Last Name____________________________________
Address: _____________________________________________________________ Apt#:____________
City:__________________________________ Province:____________ Postal Code: ________________
E-mail Address:_________________________________________________________________________
Home Phone # _____________________________ Bus/Cell Phone # _____________________________
Canadian Citizen: YES □ NO □ Landed Immigrant: YES □ NO □ If YES, since when ___________
If YES, have you been sponsored YES □ NO □
Marital Status____________________ # of Dependents and ages:_________________________________
Number of people living at this address (including non dependants & dependants): ____________________
Relation to you : ________________________________________________________________________
HELP US UNDERSTAND YOUR DIAGNOSIS
Diagnosed with Breast Cancer on (date)_______________________ Type:__________________________
Where are you being treated? Name of facility/hospital:_________________________________________
______________________________________________________________________________________
Treatment received to date: _______________________________________________________________
______________________________________________________________________________________
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Are you still receiving chemotherapy and/or radiation? YES □_ NO □_
If NO, what date was the last treatment: _____________________________________________________
Additional treatment required:_____________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
YOUR MEDICAL TEAM
Family Doctor: ____________________________________Phone Number ___________________Ext.
Oncologist’s name: _________________________________Phone Number___________________Ext.
Social Worker: ____________________________________Phone Number ___________________Ext.
The confirmation of your diagnosis and the information related to the treatments received or currently receiving or to follow must be provided by your medical team on a letterhead from the health center. This document must be signed and sent along the present form.
PLEASE HELP US UNDERSTAND YOUR FINANCIAL SITUATION
Are you receiving financial aid from the government or other institutions? YES □ NO □
If YES, please indicate the origin:____________________________ and amount: $___________________
Are you presently working? YES □ Current position: ____________________________________
Full time □__ Part time □__
NO __ If NO, state the last day of work: _______________________
Position: __________________________________________
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Your gross monthly income:
wages, child support or allowance, estate income, government pension, housing allowance, disability, old age security plan, …
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Please indicate
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Amount
$
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Your spouse gross monthly income:
wages, child support or allowance, estate income, government pension, housing allowance, disability, old age security plan, …
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Please indicate
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Amount
$
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If you are sponsored, your sponsor gross monthly income:
wages, child support or allowance, estate income, government pension, housing allowance, disability, old age security plan, …
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Please indicate
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Amount
$
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Other source(s) of income :
From other institutions and/or charities
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Please indicate
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Amount
$
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Your monthly expenses:
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Monthly Mortgage/Rental Payment
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$
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Groceries/Food
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$
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Cable/phone/internet
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$
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Utilities (hydro/water/gas)
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$
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Car payment/loan
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$
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Insurance
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$
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Other (please indicate)
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$
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Total gross revenues $______________Total expenses $_______________ Difference $_______________
PLEASE TELL US HOW THE “KELLY SHIRES FOUNDATION” CAN HELP?
Our goal is to financially assist you so that you can focus on your convalescence, we appreciate and comments/feedback:
______________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Note: -Your request should include at least one expense related to your medical treatment
-Alcohol, pop, magazines, lottery tickets, animal food and products, and plastic bags are not
eligible. Please make sure that you deduct their cost from the requested amount.
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Type of expense (please indicate)
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Amount
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Receipts to include
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Included
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Mortgage or lease (maximum allowance is $700)
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$
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Copy of current lease or mortgage statement of account
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Groceries (maximum allowance is $400)
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$
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Original cashier receipts
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Hydro, gas, expenses related to the housing (maximum allowance is $400)
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$
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Copy of the invoice(s)
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Telephone (maximum allowance is $50)
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$
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Copy of the invoice(s)
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Medication
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$
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Original pharmacy receipts
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Other medical expense(s) (please indicate)
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$
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Original receipts
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Prosthetics, bras, wigs, sleeve
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$
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Original receipts or estimate
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Transportation and gas expenses (maximum allowance is $200)
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$
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Original receipts and copy of the appointment-visit schedule
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Parking, accommodation and meal expenses during the treatment (please indicate)
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$
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Original receipts and copy of the appointment-visit schedule
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Other (please indicate)
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$
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Original receipts or copy of the invoice
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Other (please indicate)
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$
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Original receipts or copy of the invoice
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Other (please indicate)
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$
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Original receipts or copy of the invoice
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Total amount requested: $ ____________
Note: The maximum amount payable per request is $1,000. Excess amounts WILL NOT BE
carried over for a future request (some exceptions however can be made)
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AUTOGRAPH
(Applicant must sign and authorize release to confidential information)
I certify that the above information is accurate. I also understand that this information and the documents included are to be used by the Kelly Shires Breast Cancer 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?_________________________________________________
Other Comments or suggestions?___________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Kelly Shires Breast Cancer Foundation
523 Elizabeth Street, Suite #200
Midland, Ontario L4R 2A2
Telephone: 705-528-1053 Toll free: 1-877-436-6467
E-mail: info@breastcancersnowrun.org
www.kellyshiresfoundation.org www.breastcancersnowrun.org
“OFFERING FINANCIAL ASSISTANCE TO BREAST CANCER PATIENTS”
PLEASE NOTE THAT ALL FIVE (5) PAGES OF THIS APPLICATION MUST BE FILLED OUT AND SENT BY MAIL ONLY (NO FAXED APPLICATION PLEASE) SO AS TO BE ADMISSIBLE BEFORE THE COMMITTEE
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Please Read Carefully and Fully
Document Checklist for 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 MANDATORY 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.
An incomplete application will be put on “hold” until completed
In order to establish financial need, applicants MUST:
ü Provide current income tax notice of assessment (approval committee reserves the right to request previous years complete income tax return upon request).
ü Receipts (and/or estimates) MUST be provided for amounts claimed through the fund (originals are most often required).
ü Proof of citizenship/approved landed immigrant status MUST be provided.
ü Applications requesting assistance for rent or mortgage MUST include documentation supporting the amount they are requesting.
ü Each application must include an item directly related to breast cancer diagnosis and/or treatment
All personal information is protected under the Canadian Privacy Act. (kindly note that if the requested documentation is not included, it will only delay any financial assistance that could possibly be provided).
THE FOLLOWING MUST BE INCLUDED WITH YOUR APPLICATION:
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Documents to include
(use this table as a check-list, once the document is included, tick the appropriate box)
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For a 1st request
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For another request the same year
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For another request the next year
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Official document from your health center confirming the diagnosis, treatments received, current and to follow
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N/A
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Copy of your current taxes filing Federal and Provincial, and your spouse’s one if applicable
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N/A
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Copy of your current or last Tax Assessment Federal and Provincial, and your spouse’s one if applicable
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N/A
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Proof of Citizenship or landed immigrant status or Birth Certificate or copy of Passport
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N/A
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N/A
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Proof of other funding received / copy of income statement
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N/A
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Original receipts (medication, groceries, transportation, parking, accommodation, meals),/estimate
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Copy of the utilities invoices
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Copy of your current lease or mortgage statement (document showing the paid amount)
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N/A
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Application form signed by the applicant
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