NATIONAL GAUCHER CARE FOUNDATION, INC.
CARE & CARE+PLUS PROGRAMS
267 KENTLANDS BLVD., BOX 1084
GAITHERSBURG, MARYLAND 20878

APPLICATION FORM
PLEASE FILL OUT THE FORM AND PRINT IT
I. Applicant Information
 
First Name:
Last Name:
Middle Name:
Sex:
Address:
City:
State:
Zip:
Social Security #:
Date of Birth:
Phone:
Home:
Work:
   
II. Financially Responsible Party # 1
 
First Name:
Last Name:
Middle Name:
Relationship to Applicant:
Address:
City:
State:
Zip:
Occupation:
Employer:
Employer Address:
City:
State:
Zip:
Phone:
Home:
Work:
Length of Employment:
Social Security #:
Date of Birth:
# of Dependents
(include patient):
Name:
Age:
Name:
Age:
Name:
Age:
   
III. Financially Responsible Party # 2 (complete if two incomes)
 
First Name:
Last Name:
Middle Name:
Relationship to Applicant:
Address:
City:
State:
Zip:
Occupation:
Employer:
Employer Address:
City:
State:
Zip:
Phone:
Home:
Work:
Length of Employment:
Social Security #:
Date of Birth:
   
IV. Net Family Monthly Income
 
Combined Salaries (net monthly): $
Social Security Disability: $
SSI, SS Retirement: $
Private/Job Relayed Disability: $
Pensions: $
Alimony/Child Support: $
Unemployment: $
Other Income: $
   
V. General Information
 
Are you a citizen of the U.S.?
How did you learn about these Programs?
Please explain why you are applying for assistance
   
VI. Assistance Request
What Type of Assistance are you requesting?
 
CARE (Insurance Premiums)
Primary Insurance Policy
Name of Insurance Company
Cost/Month $
 
Secondary Insurance Policy
Name of Insurance Company
Cost/Month $
......................................................................................................................
CARE+PLUS(Other Gaucher Related Expenses)
Diagnostic Tests, Cost $:
Infusion Charges, Cost $:
Travel Expenses, Cost $:
Membership Fees, Cost $:
Day Care Expenses, Cost $:
Over-the-counter RX, Cost $:
Other Expense, Cost $:
   

VII. Request For Additional Information
 

THIS APPLICATION CANNOT BE PROCESSED WITHOUT THIS INFORMATION

1.Please include copies of your three most recent IRS Income tax returns (all schedules).
2. Please include copies of your three most recent bank statements from all accounts (checking, savings).
3. Please include copies of your three most recent investment account statements.
4. Please have your physician complete the medical statement of need included in the brochure.
 

VIII. Certification Statement
 

I certify that the information contained in this application is complete and accurate to the best of my knowledge and agree to notify the NGCF of any changes with which I become aware.

Signature:
  Applicant or financially responsible party
Date:

All information provided by an applicant will be held in the strictest confidence and is the sole property of the NGCF, its staff, and advisory board. No information provided to the NGCF will be released to any other organization or entity unless the applicant signs an appropriate release of information.

Please keep copies of all correspondence sent to the NGCF including the application, financial statements and any other information provided to the NGCF.

Please note that it is possible that grant requests made by a qualified applicant may be denied due to requests exceeding available funds. This application in no way guarantees or entitles applicants grants.