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APPLICATION FOR ASSISTANCE
CANCER FOUNDATION OF THE FLORIDA KEYS, INC.
Today's Date:
Applicant Name:
First Name
Last Name
Diagnosis
What Living Expense Assistance is Needed?
Applicant Phone Number:
Applicant E-Mail Address:
Date Of Birth:
Social Security Number:
SS Number
Gender:
Male / Female
Applicant Street Address
Street Address Line 2
City
State
Zip Code
Emergency Contact Phone Number:
Emergency E-mail Contact:
Applicant E-mail Address
Emergency Contact Information:
Applicant Proof of Residency:
Drivers License Number
Upload Copy Drivers License / ID
Total Household Income (Include income of all persons living in the home)
Total Household Income
Income Verification:
1. Federal Income Tax Return
FIRST PAGE ONLY
- Upload most recent Income Tax Return (2 Years)
FIRST PAGE ONLY - Tax Return - Year 1
FIRST PAGE ONLY - Tax Return - Year 2
Tax Return - Year
Copy of Most Recent Treatment Plan. A Treatment Plan is a statement from your Oncologist indicating:
1) Diagnosis
2) Treatment Applicant is Currently Receiving, and
3) Length of Applicant Expects to Receive Treatment for Cancer.
** DO NOT INCLUDE complete medical history, ie. record of office visits, or any documentation that does not pertain to the Treatment Plan.
Your Application will not be considered unless a Current Treatment Plan is provided.
Treatment Plan
Have you applied for food and medical assistance from the state of Florida? (Select One)
Yes
No
Please Upload a Letter of Assistance or Denial.
Amount of Rent / Mortgage:
Upload Lease Agreement or Mortgage Information
Lease / Mortgage Paperwork
I understand and agree that the information supplied by me may be shared with other funding sources, and community services for benefits and planning on my behalf:
Please initial:
I attest that I am a resident of Monroe County and that I must pursue all relevant Federal, State, Local, Public and Private Resources for medical and financial assistance in a timely fashion before, and co-incidental with receiving any financial assistance from the Cancer Foundation of the Flrida Keys, Inc.
Please initial:
I understand that I may be ineligible for service if, at any time, I have been found to have deliberately misled any representative of the Foundation.
Please initial:
Applicant Signature:
Date: