Financial Assistance Form

Kevin Halewood Foundation

If you wish to apply for financial assistance, please complete the form below. To accurately assess your financial situation and determine your eligibility, the following information is required and must be filled out in its entirety or it  will be rejected.

All information submitted is strictly confidential.

  1. Complete and sign the Financial Assistance Application form below.
  2. Attach a copy of your or responsible parties’ most recent Federal and State Income Tax Returns and W-2s for all members of your household. Include all schedules and pages. If you do not file a tax return, please include a letter of non-filing for the Internal Revenue Services (IRS).
  3. Attach a copy of the last two Pay Check Stubs for all members of your household. If paid by cash, please submit verification of employment and salary on company letterhead.
  4. Attach a copy of the last two Bank Statements and/or Debit Card Statements for all accounts for all members of your household.
  5. Attach a copy of the most recent SSD/SSI Award Letter for all members of your household.
  6. Attach a copy of the most recent Proof of Child Support, Pension, and/or Unemployment Benefits for all members of your household.

If these documents are not available, please explain why in the Additional Information section below.

  1. Attach a copy of Insurance Card/Medicare/Medicaid Card for all members of your household.

"*" indicates required fields

Name*
MM slash DD slash YYYY
Marital Status*
Specific Medical Care Needed*
Address*
If the patient is an adult, include the patient, the patient's spouse/significant other, and any dependents living in the home. If the patient is a minor, include the patient, the patient's father, dependents of the father, the patient's mother, and dependents of the patient's mother.
Income is defined as cash receipts before taxes and includes but is not limited to: wages, salaries, child support, alimony, Social Security and disability benefits, unemployment compensation, VA benefits, workman's' compensation, business income/loss, pension, income from real estate. If the patient is a minor, include the patient, the patient's father, dependents of the father, the patient's mother, and dependents of the patient's mother.
Include all bank accounts, savings accounts, retirement accounts (IRA, Pension Fund, 401k, 403b, etc.) If the patient is a minor, include the patient, the patient's father, dependents of the father, the patient's mother, and dependents of the patient's mother.
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