Homie's Hope Financial Assistance Application
**Hello all, due to the high number of applicants we are currently on a waiting list through May 2020. Please fill out the form and we will be in contact at a later date.**
Email address *
Name *
Your answer
Name of Mitochondrial affected individual *
Your answer
Age of Mitochondrial affected individual *
Your answer
Relationship to Mitochondrial affected individual *
Your answer
Name and ages of individuals in household, monthly incomes and relationship(Complete as: Name/age/monthly income/relationship). *
Your answer
Address, City, St, Zip *
Your answer
Previous Addresses in last 10 years. Add, city, St, Zip *
Your answer
Phone number (1234567890) *
Your answer
Annual(Yearly) Income
Responsible party's gross annual(Yearly) income (before taxes) *
Your answer
Other household gross annual(Yearly) income (before taxes) *
Your answer
Annual(Yearly) household income from all sources (before taxes) *
Your answer
Monthly Income
Child support/alimony received monthly *
Your answer
Other Income (description and amount) *
Your answer
Monthly household expenses
Rent/Mortgage/Homeowner's Insurance Monthly *
Your answer
Mortgage Lender Company *
Your answer
Utilities (Electricity/Water/Gas) Monthly *
Your answer
Monthly Phone Expenses *
Your answer
Child Support/Alimony Paid(You Pay) Monthly *
Your answer
Food (excluding cigarettes and alcohol) monthly *
Your answer
Car Payment (Loan & Insurance) monthly *
Your answer
Medical and Pharmacy bills YTD(not monthly) *
Your answer
Other monthly expenses *
Your answer
Total Monthly Expenses: Please total all expenses and estimate monthly medical and pharmacy bills *
Your answer
Other Info
What type of health insurance do you have? *
Your answer
Have you or are you receiving contributions from other organizations? If yes what organization and how much? Is it a one time contribution? *
Your answer
Do you receive any type of federal assistance? If so, what and how much? *
Your answer
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. *
Your answer
Reason for applying – ie medical expenses, trip funding, college expenses, vehicle, vehicle/home modifications, etc. Please be specific on what you need assistance with. *
Your answer
What is the minimum amount of financial assistance that would help you/your family? Please provide a dollar amount. *
Your answer
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. *
Your answer
If selected for assistance, how will it affect your life/lives? *
Your answer
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? *
Your answer
How did you hear about Homie's Hope? *
Your answer
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
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.
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.
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