Grant Request Application

Applicant Information

Date*

Patient Name*

First Last

Date of Birth*

Address*

Street Address City State ZIP Code

Phone*

Marital Status*

Number of Dependents*

Ages of Dependents:

Agency Information

Agency Name*

Agency Address*

Street Address Address Line 2 City State ZIP Code

Social Worker or Contact Name*

First Last

If approved, payment should be made to the following vendor:

Vendor Name*

Address*

Street Address Address Line 2 City State ZIP Code

Vendor Phone Number*

Vendor Email*

Description of Request

* If requesting utility or any payments for which there is an account and account number, please attach documentation indicating the account holder’s name and account number. In some circumstances, the account holder’s SSN may be requested by the HPF in order to apply the grant payment to the proper account.

Select one:*

Rent
Utilities
Emergency Repair
Food Assistance
Comfort Care/Personal
Last Wishes
Burial/Cremation

Total Cost of Request*

In order to best serve all hospice patients in need, please capture the total cost of the request so that the board may use this information in deciding the grant amount allowed.

Grant Amount Requested*

The current cap on rent, utility, emergency repair, food assistance, comfort care/personal, and last wish requests is $1,100. The current cap on burial/funeral costs is $1,500. In certain circumstances, the board may review and approve requests for greater than this amount. Please indicate here the grant amount you are asking the HPF to fulfill.

Explanation of Request:*

Has the patient passed away?*

Yes
No

Date of Death*

Explanation:*

Required Additional Documentation

Supporting financial documentation

File*

Drop files here or

Max. file size: 50 MB.

Financial Needs Assessment

Name of Grant Recipient

First Last

Please provide any of the following items that are applicable in order to confirm grant recipient’s household monthly income AND reserves. This documentation must be uploaded.

Most recent Federal / State income tax forms
Unemployment check stubs/paycheck (3mths)
Statement of monthly benefits from SS
Life insurance policy documentation
Documentation of other investment accounts
W-2 withholding statements and/or 1099
Copy of proof of pension amount
Approval/Denial forms of public aid, unemployment, and worker’s compensation
401k/Retirement account balance
Regular savings and/or checking acct balance

Upload supporting documentation here:*

Drop files here or

Max. file size: 50 MB.

STATED/CONFIRMED GRANT RECIPIENT’S MONTHLY INCOME:*

STATED/CONFIRMED GRANT RECIPIENT’S RESERVES VALUE:*

Based on grant recipient’s income and applicable family or household size, please select the current number of individuals living in the household.

Please refer to the table below.

Monthly Income	1	2	3	4
Les than/equal to	$2,265	$2,818	$3,051	$3,838
Montly Income	5	6	7	8 or >
Less than/equal to	$4,625	$5,411	$6,198	$6,985

*Add $393 for each person over 8

Consent*

By including my name below I attest that I have pursued all other avenues possible, including private insurance, governmental and charitable agencies providing funding, and relief from financial obligations as well as public aid. Therefore, I hereby request that The Hospice Promise Foundation make a determination of this hospice patient’s eligibility for grant assistance. I understand that the information submitted concerning the patient’s/family’s annual income, family size, and asset reserves, is subject to verification by The Hospice Promise Foundation.

Name*

First Last

Procedure for Completed Application

All completed grant request applications should be accompanied by the financial needs assessment documentation and are subject to limits established by the Foundation guidelines. Requests will be sent to The Hospice Promise Foundation Board for review. A representative of the Foundation will contact you within 72 hours of receipt. If request for funds is emergent, an answer will be sent within 24 hours of receipt. The Foundation, as a non-profit entity, may require a follow-up report to verify the donation was spent in accordance with this request. Please designate the individual(s) responsible for submitting a follow-up report and supplying the requested information.

Name of Agency Submitter*

First Last

Date*

Submitter Phone Number*

Submitter Email*

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