Pink Helping Hand Application – Returning Applicant

1. APPLICANT INFORMATION

First name

Last name

Date of birth

Phone number

Current Address

Street number

City, State

Zip code

2. CURRENT TREATMENT INFORMATION

Date of breast cancer diagnosis

Are you currently receiving treatment?  

Yes No

Medical provider's name / Oncology practice

Provider 's phone number

Approximate treatment end date, if known:

3. PREVIOUS HELPING HAND ASSISTANCE

Have you previously received financial assistance from Pink Helping Hand? 

Yes No

Date of previous assistance:

Amount previously received:

What was the previous assistance used for?

4. REASONS FOR ADDITIONAL ASSISTANCE

Please explain your current financial hardship:

When did this financial hardship begin?

5. SUPPLEMENTAL ASSISTANCE REQUESTED

Amount of additional assistance requested:

Please explain specifically how the additional funds will be used:

Is there a specific bill or expense that needs to be paid?

Yes No

If yes: Type of bill/expense

Amount due

Due date

6. HOUSEHOLD & FINANCIAL CHANGES

Since your previous Pink Helping Hand application, has anything changed financially?

Yes No

If yes, check all that apply:

7. OTHER ASSISTANCE

Are you currently receiving financial assistance from another organization?

Yes No

If yes, please list the organization(s) and type of assistance:

Have you applied for assistance from another organization for this current hardship?

Yes No

If yes: Organization

Outcome

8. SUPPORTING DOCUMENTATION

Please provide documentation supporting your request, when available

Current medical treatment verification, if requested Proof of income or recent change in income Bill or statement for the expense being requested Rent/Mortgage statement Utility bill Medical bill Other supporting documentation

Additional documentation provided:
Accepted formats: PDF, JPG, JPEG, or PNG

9. APPLICANT STATEMENT & SIGNATURE

Sign

I certify that the information provided in this application is true, accurate, and complete to the best of my knowledge. 
I understand that this application is for supplemental financial assistance due to a financial hardship occurring during my breast cancer treatment. I understand that submitting this application does not guarantee additional assistance. 
I authorize United Colors of Pink to review the information and supporting documentation provided for the purpose of determining eligibility for supplemental assistance. 
I understand that United Colors of Pink may request additional documentation or clarification before making a decision.

Signature

Printed Name:

Date

Pink Helping Hand

Application for Applicants Currently Receiving Assistance from UCP