Jill's Wish Grant Program Assessment Questionnaire
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Name of Applicant *
Address of Applicant *
Contact Telephone Number *
Contact Email Address: *
Applicant Date of Birth *
Have you been diagnosed with breast cancer? *
Diagnosis *
Date of Diagnosis *
Name and Address of Treating Oncologist, Physician or Other Provider *
Is your diagnosis terminal? *
Have you received grant money or funding from Jill's Wish before? *
If so, when did you receive funding?
What is your total combined annual household income? *
How many members are in your household? *
Are you currently receiving or will you be receiving any government assistance or benefits? *
Are you currently receiving or will you be receiving any additional financial assistance while undergoing treatment such as retirement monies or a pension? *
Is the current balance of all combined household bank accounts LESS THAN $3,000? *
Will you be able to provide copies of all of the following information: a W2 form, recent paystub (if applicable), government-issued identification and banking records? *
Will you be able to provide copies of all applicable living expenses (including utility bills, mortgage or rent payment receipts and car payments, if applicable)? *
If selected to receive a grant, will you be able to provide information regarding where and to whom you pay your living expenses? *
If awarded one of our grants, how would the money benefit you? *
Please provide us with two references (can be personal or professional) who can verify your situation. *
Please include name, telephone number and email address.
Please feel free to provide us with any other information regarding your current situation and diagnosis.
If selected to receive one of our grants, you will be required to sign a release giving Jill's Wish permission to pay bills on your behalf. Additionally, funds must be used within 30 days of being awarded (funds awarded will cover one month of bills) and will be paid directly to the appropriate utility companies, mortgage lenders, landlord, housing association, auto loan lender or any other applicable account or creditor. Do you agree to these terms? *
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