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APPLICATION FOR ASSISTANCE

CANCER FOUNDATION OF THE FLORIDA KEYS, INC.


 

Today's Date: 

 

Applicant Name:

 

Diagnosis


What Living Expense Assistance is Needed?




Applicant Phone Number:



Applicant E-Mail Address:




Date Of Birth:

Social Security Number:



Gender: 
Male / Female

 

Applicant Street Address







Emergency Contact Phone Number:

Emergency E-mail  Contact:


Emergency Contact Information:



Applicant Proof of Residency:

Total Household Income (Include income of all persons living in the home)

 

Income Verification:

FIRST PAGE ONLY - Tax Return - Year 1                                 


 FIRST PAGE ONLY - Tax Return - Year 2    
 


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.



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

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: