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Breast Cancer Fact  
20% of breast cancer cases occur in women aged 30-49.
28% of breast cancer cases occur in women aged 50 to 59.
Application for Financial Assistance Minimize

 

                  

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: __________________________________________

 

Your gross monthly income:

wages, child support or allowance, estate income, government pension, housing allowance, disability, old age security plan, 

Please indicate

 

 

Amount

$

Your spouse gross monthly income:

wages, child support or allowance, estate income, government pension, housing allowance, disability, old age security plan, 

Please indicate

 

 

Amount

$

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, 

Please indicate

 

 

Amount

$

Other source(s) of income :

From other institutions and/or charities

Please indicate

 

Amount

$

 

Your monthly expenses:

Monthly Mortgage/Rental Payment

$

 

Groceries/Food

$

 

Cable/phone/internet

$

 

Utilities (hydro/water/gas)

$

 

Car payment/loan

$

 

Insurance 

$

 

Other (please indicate)

 

$

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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.

                                                                                                                                                                  

Type of expense (please indicate)

Amount

Receipts to include

Included

Mortgage or lease (maximum allowance is $700)

 

$

Copy of current lease or mortgage statement of account

 

Groceries (maximum allowance is $400)

 

$

Original cashier receipts

 

Hydro, gas, expenses related to the housing (maximum allowance is $400)

 

$

Copy of the invoice(s)

 

Telephone (maximum allowance is $50)

$

Copy of the invoice(s)

 

Medication

 

$

Original pharmacy receipts

 

Other medical expense(s)  (please indicate)

 

$

Original receipts

 

Prosthetics, bras, wigs, sleeve

 

$

Original receipts or estimate

 

Transportation and gas expenses (maximum allowance is $200)

 

$

Original receipts and copy of the appointment-visit schedule

 

Parking, accommodation and meal expenses during the treatment  (please indicate)

 

$

Original receipts and copy of the appointment-visit schedule

 

Other (please indicate)

 

$

Original receipts or copy of the invoice

 

Other (please indicate)

 

$

Original receipts or copy of the invoice

 

Other (please indicate)

 

$

Original receipts or copy of the invoice

 

 

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:

 

Documents to include

(use this table as a check-list, once the document is included, tick the appropriate box)

 

For a 1st request

For another request the same year

For another request the next year

Official document from your health center confirming the diagnosis, treatments received, current and to follow

 

N/A

 

Copy of your current taxes filing Federal and Provincial, and your spouse’s one if applicable

 

N/A

 

Copy of your current or last Tax Assessment Federal and Provincial, and your spouse’s one if applicable

 

N/A

 

Proof of Citizenship or landed immigrant status or Birth Certificate or copy of Passport

 

N/A

N/A

Proof of other funding received / copy of income statement

 

N/A

 

Original receipts (medication, groceries, transportation, parking, accommodation, meals),/estimate

 

 

 

Copy of the utilities invoices

 

 

 

Copy of your current lease or mortgage statement (document showing the paid amount)

 

N/A

 

Application form signed by the applicant

 

 

 

 

 

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