Application for Support

Are you between 18 and 29 years of age? (Circle One) Yes / No

Are you currently in treatment? (Circle One) Yes / No
Is this your first request to the NJHF? (Circle One) Yes / No
Are you requesting a fiscal receivership? (Circle One) Yes / No

CONTACT INFORMATION:
Name: _______________________________________________ Gender: (Circle One) Male / Female
Address: ______________________________________________________ Birth Date: _______________

City: ________________________________________ State: _______ Zip-code: ___________________

Phone: ________________________________ E-mail: _________________________________________

Name of Medical Insurance: _______________________________________________________________

Living Alone: (Circle One) Yes / No Marital Status: (Circle One) Single / Married / Widowed / Divorced
Children’s Name(s) / Age(s): _______________________________________________________________
Employer: ____________________________________ On Disability: (Circle One) Yes / No
Last Date Worked: _______________ Supervisor’s Name/Phone: ________________________________

Spouse’s Name: _____________________________ Spouse’s Employer: ___________________________

FINANCES:
Rent/Mortgage: $ ______________ Utilities: $ ______________
Health Insurance: $ _____________ Other Monthly Expenses: $ _____________
Total Monthly Expenses: $ _________________
Totally Monthly Income: $ __________________

TREATMENT:
Housing Status: (Circle One) Home / Hospital / Care Center / Other: _______________________________
Type of Cancer: _________________________________________________________________________
Current Treatment Protocol: _______________________________________________________________

REQUEST:
What financial assistance can we provide? (Circle One) Rent / Mortgage / Utilities / Car / Medical
Insurance / Other: ________________________________________________________________________

Don’t forget to attach your doctor’s verification letter and a copy of your bill, receipt, mortgage
statement, lease agreement, or documentation of your request.

Applicant’s Signature ___________________________________________ Date: ____________________