Josette Beddell Memorial Foundation Online Financial Hardship Grant Application
The mission of the Josette Beddell Memorial Foundation is to help better the lives of families in Ohio affected by cancer. Breast Cancer doesn’t just affect the patient, it affects the whole family: physically, emotionally and financially. We work to raise funds and find families in our community where those funds could make a positive impact on their lives. Our foundation is rooted in the ideals of Josette Beddell, who lost her battle with breast cancer but lived her life working to better the community she lived in.

Note: please allow 4-8 weeks for processing. Please answer all questions below:

Today's Date *
MM
/
DD
/
YYYY
Information about applicant:
Applicant First and Last Name *
Your answer
Applicant Address *
Your answer
City, State, Zip *
Your answer
Applicant Phone Number *
Your answer
Applicant Email Address
Your answer
Preferred Method of Communication *
Date of Birth
MM
/
DD
/
YYYY
Marital Status *
Your answer
Number of Dependents *
Your answer
Information about illness
Approximate Date of Breast Cancer Diagnosis *
Your answer
Please tell us about your experience with breast cancer: *
Your answer
Applicant financial information
In your own words describe your financial hardship (ex. Loss of job due to illness, medical bills exceeds income; need to travel long distance for medical treatment, etc): *
Your answer
Annual Household Taxable Income *
Your answer
Monthly Rent/Mortgage Payment *
Your answer
Monthly Utility Costs *
Your answer
Monthly Out of Pocket Insurance Co-Pay (if applicable)
Your answer
Monthly Misc. Out of Pocket Expenses (please explain in detail) *
Your answer
Any Additional Expenses caused by the hardship? *
Your answer
Request for assistance? *
Your answer
How did you hear about us? *
Your answer
If there was one thing you could do if money was no object what would it be?(ex: Dream vacation, spa day, birthday party for child, etc) *
Your answer
Is there anything else you would like us to know about you?
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Josettememorial.org. Report Abuse - Terms of Service - Additional Terms