Assistance Application |

Tell us about who you are and where you live

Applicant Name*

First Last

Current Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone*

Cell Phone*

Email*

Date of Birth*

Is anyone applying on your behalf?*

Yes
No

Please provide name and phone number of person applying on your behalf.*

First Last

Phone Number*

How did you hear about us?

The following information is collected to be sure that everyone is served fairly without regard to race, color, or national origin. The information provided will not affect your eligibility or benefit amount.

Tell us what you need assistance with and why?

i.e. Utility bills, rent/mortgage, medical bills, medication, travel expenses for doctor visits, car payments.

Please upload a copy of the bills that you would like to be paid*

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 512 MB.

What is your diagnosis?*

Please provide MRI Report, Pet Scan Report or Letter from Oncologist*

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 512 MB.

Digital Signature*

Applicant Acceptance of below:

I certify that above information along with any attachments are true and complete to the best of my knowledge. I understand that this application must be approved by the majority of the Board of Directors at C.U.C.F and that I (of the person that applied on my behalf) will be notified if approved. I fully understand that this is a one-time donation. I also understand that the donation will be payable to an organization, lender, or company not to me personally.

Applicant's Signature*

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Name

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Assistance Application

$1,000 Maximum Assistance

Tell us about who you are and where you live

Do you have questions?

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