CANCER FOUNDATION OF THE FLORIDA KEYS APPLICATION FOR ASSISTANCE

Street (and Unit Number):
City:

Applicant Primary Phone Number:

Support / Caregiver Contact Information:

First and Last Name:


Support / Caregiver Phone Number:

Applicant Proof of Residency:

Driver's License Number:

Upload ID (Driver's License)

Income Verification:

Total Household Income (Please include income of all persons living in the house):

 

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

Most Recent Paystub(s) of All Wage Earners in Household: Upload Paystubs



DIAGNOSIS:

Attach the Most Recent Treatment Plan.   The Treatment Plan is a statement from your Oncologist indicating:

1) Diagnosis,

2) Treatment you are receiving, and

3) the Length of time you are expected to receive treatment for Cancer.  

 

* Do not include complete medical history, ie. records of office visits, or any documentation that does not pertain to the Treatment plan. 

Your Application will not be considered unless the Current Treatment plan is attached.

Upload Treatment Plan Here

Have you applied for food and medical assistance from the state?
Enter Yes or No
 
Upload Letter(s) of acceptance or denial:


Rent/Mortgage Assistance Request:
Total Rent / Mortgage Amount
Upload Lease / Mortgage Coupon
Name of Landlord (if applicable):

First Name

 Last Name
Name of Landlord Phone Number:


Utlitiy Bill(s) Request:

Upload Utility Bills Here
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.

Initial

Applicant Signature:
 

Applicant Printed Name: