Financial Aid Application

The Merced Cancer Society Foundation is dedicated to supporting cancer patients in need. Assistance is available in various forms, depending on funding and volunteer availability. The level of support we provide is determined by individual needs, income, and circumstances.

To ensure we can assist you effectively, please provide and verify your household income, any relevant medical insurance information, and a letter from your oncologist confirming your diagnosis.

Grant Registration

Please answer all questions completely and to the best of your knowledge in order to prevent delaying this application. Copies of income, countable resource and expenses MUST be included or application will be rejected as incomplete.

PERSONAL INFORMATION

Applicant's Name

First Last

Mailing Address(Required)

Mailing Address Physical Address, if different City State ZIP Code

Main Phone(Required)

Cell Phone, if different

Work Phone

HEALTH & INSURANCE INFORMATION

Medical Insurance?(Required)

Yes

If Yes, what insurance company:

Policy Number

Group Number

Other Coverage?

Yes

If Yes, what is other coverage:

Are you currently under the care of an Oncologist?(Required)

Yes

Date Care Started:

Name of Doctor:

Facility Name:

FINANCIAL INFORMATION

List the people that reside in your household. Please list each person’s monthly income. (Paychecks, welfare, unemployment, child support, gifts or grants, etc)

People who reside with you

Name

Relationship

Birthdate

Monthly Income

Name

Relationship

Birthdate

Monthly Income

Name

Relationship

Birthdate

Monthly Income

Name

Relationship

Birthdate

Monthly Income

Name

Relationship

Birthdate

Monthly Income

Are you currently employed?(Required)

Yes

If no, why?

Length of Employment:

Current Employer

Employer Address:

Include Street | City

Employer Phone

Household Monthly Income & Expenses

PLEASE SUPPLY COPIES OF SUPPORTING DOCUMENTS

Income

Wages

Tips

Alimony/Child Support

Social Security

Pension

Income - continued

Military Family Allotments

Income from Interest

Food Stamps

Retirement

Unemployment

Total Income

Income - continued

General Relief

Income from Dividends

Income from Rent

Strike Benefits

Other Income (explain)

Total Income

Expenses

Rent Payment

Mortgage Payment

Food

Gas

Electricity

Phone

Expenses

Sewer/Garbage

Other Medical

Other (Specify)

Total Expenses

Explain your current situation:

Document upload | Consent

Date(Required)

Signature(Required)

Document Upload(Required)

Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 64 MB.