Health Care Gap Fund Grant Application

This is the Washington Women in Need Health Care Gap Fund Grant Application form.

In order to be considered for this grant, you must submit a completed application. For your application to be complete, you must submit both this electronic application as well as the required supporting documentation outlined below. The entire application--this online form plus the supporting documentation--must be received within the same calendar month for you to be considered. If either your online application form or your supporting documentation is missing from your application, you will not be considered, and submitted documents will not be maintained.

Because of this, we strongly encourage you to have all of your documentation ready for submission (via email, fax, or mail, which will be described in further detail on the last page of this form) before you complete this online application.

So please review the below list of required documentation and confirm that you have all of them before you proceed.

If you have Apple Health insurance coverage, we need:
- A copy of your Washington Driver's License or State ID
- A copy of your Apple Health Services card
- A copy of your Apple Health insurance coverage plan Identification Card
- Documentation that you have a need for one of the services WWIN will fund (for example, a dental treatment plan or a prescription for glasses or contact lenses)

If you have Medicare insurance coverage, we need:
- A copy of your Washington Driver's License or State ID
- A copy of your Medicare card
- Copies of the first two pages of your most recently completed Federal tax return or your last six months' of bank statements, if you do not file taxes
- If you are a dependent, copies of your parents'/guardians' most recently completed tax return(s) or their last six months' worth of bank statements, if they do not file taxes
- If you have it, documentation that you have a need for one of the services WWIN will fund (for example, a dental treatment plan or a prescription for glasses or contact lenses)

If you do not have one or more pieces of supporting documentation, you should not complete this online application at this time. You should wait until a future month in which you have all supporting documentation ready for submission.

If you are confused about exactly what is needed, you should not complete this online application at this time. Instead email our Programs team at programs@wwin.org to ask for assistance.