Financial Assistance Grant Application

Please complete our Financial Assistance Grant Application

**Please allow 14 business days for the initial review process**

Today's Date

YYYY

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date of Birth

YYYY

Age

Date of Diagnosis

YYYY

Stage of Cancer

Is this a relapse.

Treatment

Please list treatments you have received to-date: Orchiectomy, BEP x3, RPLND etc.

Date of last treatment

Planned Upcoming Treatments

Orchiectomy, BEP x3, RPLND etc.

What is your living situation?

How many children in household

List age of each child. Example: 3, 5, 10

Caregiver Name/Relationship

Please enter name of person assisting with your care that we may also contact with questions regarding your application if you are unavailable

Caregiver Phone Number

(###)

###

####

Caregiver Email

Physician or Social Worker Name

Physician or Social Worker Phone Number

(###)

###

####

Treatment Facility Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please tell us your story

Employment Information

Name of Employer, job title, are you currently working?

Current Monthly Income During Treatment

List sources of income; employment, unemployment, social security income, disability

Monthly Income of Spouse/Significant Other/Partner if contributing to household (N/A if living with parents/family)

Please list your partner's monthly income if you share a household.

Do you have health insurance? Are medications covered?

If you are receiving disability, how much per month?

Have you applied for short term disability?

Approved, denied or pending?

401 (k), retirement, bonds/stocks, IRA account totals

Total Dollar Amount of all bank accounts

Mortgage Payment

Rent Payment

Car Payment

Phone/Internet/Cable

List total amount of monthly bills for phone/internet/cable

Water/Electric/Gas/Utilities

List total amount of monthly bills for water/electric/gas/utilities

Monthly Gas Expense

Monthly Grocery Expense

Other Expenses

Have you set up any personal fundraisers?

List any personal fundraisers for community support such as GoFundMe, Facebook, etc.

Link to personal fundraiser

Please add link to personal fundraisers here

http://

Does the medical center where you are receiving treatment offer financial assistance for copays?

List all other organizations you have received funds from and total amount.*

Name of organization and dollar amount received

If you are approved for TCAF's financial assistance grant, do you give consent to share your story and photos?

TCAF website, social media, emails, newsletters etc.

How did you hear about this program?

I certify that the facts set forth in this application are true and complete to the best of my knowledge. I understand that any false statement, omission or misrepresentation in my application may result in the rejection of my application.

Type Full Name - This serves as an e-signature