Homie's Hope Financial Assistance Application
Applications are no longer being accepted as we are dissolving and all funds have been allocated. 



Sign in to Google to save your progress. Learn more
Email *
Name *
Name of Mitochondrial affected individual *
Age of Mitochondrial affected individual *
Relationship to Mitochondrial affected individual *
Name and ages of individuals in household, monthly incomes and relationship(Complete as: Name/age/monthly income/relationship). *
Address, City, St, Zip *
Previous Addresses in last 10 years. Add, city, St, Zip *
Phone number (1234567890) *
Annual(Yearly) Income
Responsible party's gross annual(Yearly) income (before taxes) *
Other household gross annual(Yearly) income (before taxes) *
Annual(Yearly) household income from all sources (before taxes) *
Monthly Income
Child support/alimony received monthly                                 *
Other Income (description and amount)                                                                               *
Monthly household expenses
Rent/Mortgage/Homeowner's Insurance Monthly *
Mortgage Lender Company *
Utilities (Electricity/Water/Gas) Monthly *
Monthly Phone Expenses *
Child Support/Alimony Paid(You Pay) Monthly *
Food (excluding cigarettes and alcohol) monthly *
Car Payment (Loan & Insurance) monthly *
Medical and Pharmacy bills YTD(not monthly) *
Other monthly expenses *
Total Monthly Expenses: Please total all expenses and estimate monthly medical and pharmacy bills *
Other Info
What type of health insurance do you have? *
Have you or are you receiving contributions from other organizations? If yes what organization and how much? Is it a one time contribution? *
Do you receive any type of federal assistance? If so, what and how much? *
Has anyone in the household been convicted of a felony? If yes, please describe the crime - state nature of the crime(s), when and where convicted and disposition of the case. This does not automatically exclude you from our selection process, each situation will be reviewed and considered.   *
Reason for applying – ie medical expenses, college expenses, vehicle, vehicle/home modifications, etc. Please be specific on what you need assistance with and why. *
What is the minimum amount of financial assistance that would help you/your family? Please provide a dollar amount. *
How does mito affect the individual’s everyday life? You may attach another sheet providing more information and/or photos explaining your story if necessary. *
If selected for assistance, how will it affect your life/lives? *
If selected, are you willing to send your story and pictures on how we assisted you/your family and then allow us to share your story? ie brochures, media (fb, twitter, website) etc? *
How would you like to be notified if you are selected? Email or Phone? *
How did you hear about Homie's Hope? *
If your application is selected, the next step of the process will be to provide the Board of Directors with the following:
1. Signed consent form for a background check
2. Signed medical release consent form  
3. For requests of assistance over $500 - copy of last 2 months monthly expenses…utilities, car, medical, etc. For requests under $500 - copy of last months monthly expenses. This includes all expenses that were included on this application.
4. Copy of previous years taxes, 1099, Social Security/Disability Awards Letter.
5. Doctor’s note stating the Mitochondrial Disease diagnosis
Please be advised that the financial assistance process takes approximately 3 months.                                                              Please be advised an interview may need to be conducted between you and members of the Board. Payments for assistance will be made directly to vendors/companies, payments will not be sent to recipients.
Information provided on the application will only be viewed by Homie's Hope Board of Directors.  Applications will be kept on file according to Indiana state guidelines.
A household may only receive $10,000 in assistance in a 24 month period, from the date the assistance was received..

Contact: Info@homieshope.org
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms