EmailMe Form - Stephanie Vest Foundation Grant Application

First Name *

Last Name *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone Number *

### - ### - ####

Email *

Names and ages of all family members living in your home:
(This may be verified by a review of copy of current tax return.) *

Marital Status *

single

married

divorced

widowed

Type of Cancer *

Date of cancer diagnosis? *

MM / DD / YYYY

Stage of Cancer *

Primary Physician Name - include office address and phone number: *

Please note, a written diagnosis from treating physician will be required.

Treatment Plan *

Please tell us about yourself. What are your personal circumstances? *

What is your specific financial need? (Please keep in mind, that our financial grants are designed to "bridge the gap" when a family faces hardships due to a cancer diagnosis. We can pay living expenses due to lost wages if you cannot work or care for your family due to cancer treatment/recovery.)

**Our foundation CANNOT pay medical bills.** *

Annual Household Income: *

Bank statements may be requested to verify information.

Source of Income *

Occupation: *

Employer contact information:

Have you lost wages due to the diagnosis? If yes, please explain. *

Are you able to work? (If you are a stay-home mom, are you able to take care of your children?) *

Have you filed for or received any other assistance? (i.e. Long-term or short-term disability) If yes, please detail. *

Is your situation appropriate for Social Security Disability? If yes, have you filed? *

Current checking account balance *

Current savings account balance *

Living Arrangements *

rent

own

living with family

other

If other, please explain:

Monthly mortgage or rent payment: *

Total outstanding medical bills: *

Total monthly car payment(s): *

Total credit card debt: *

Loan Balances and type: (i.e. student loan, second mortgage, personal debt.) *

Monthly bills - Detail your monthly budget: *

Please list the following recurring monthly expenses:
Electric, Gas, Water, Food, Cable/Internet, Cell Phone, Auto/Home Insurance, Health Insurance, Childcare, gasoline/transportation, Misc. (diapers, clothes, toiletries, uniforms, etc)

Do you have health insurance? *

yes

no

Primary Insurance Provider: *

Please include company name, policy number and contact info.

Do you have a personal website that you would like us to share with our online subscribers? Please provide the link: *

Please list personal website, blog, Facebook page, CaringBridge site, etc.

Have you filed for or received any other grants? If yes, please detail. *

How did you hear about the Stephanie Vest Foundation? *

-I certify that information contained in this application is true and complete.
-I authorize the verification of any or all information listed above.
-The Stephanie Vest Foundation may choose to pay bills directly.
-Please note, the average financial assistance given by the foundation is $1,000.
-I understand that false information will eliminate me from the application process and any future assistance.

** The Stephanie Vest Foundation CANNOT pay for medical bills. **

Our Director of Financial Aid will screen each application and schedule all personal interviews. Applications and interviews will be reviewed and approved/denied by the Board of Directors at the monthly Board meetings.

Do you agree with the terms and conditions? *

Yes, I agree.

Initial *

Date *

MM / DD / YYYY

If selected for a grant, can we share your story on the Stephanie Vest website/blog/Facebook page?

yes

no