Help Now Fund Application2017-09-06T10:56:12+00:00
Help Now Fund Online Form

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2017 Help Now Fund Online Submission

The Help Now is a program for breast cancer patients, providing financial assistance for rent or mortgage, utility bills, cell phone bills, and car payments. All qualifying applications will be submitted to the committee and considered for aid.

Consideration and/or Submission DOES NOT GUARANTEE funding. Due to limited funds, eligible applicants are NOT guaranteed approval.

Before you begin please review all the FAQs, video, and required documentation. Applicants who do not submit all required documentation, in a clear, readable format, WILL NOT BE NOTIFIED that their application is incomplete.

To be considered the Applicant must:
1. Provide a copy of valid U.S. issued identification
2. Provide current (within 90 days) copies of bills and/or rental agreement, if the lease is out of date please provide us with a renewal letter. All documents must be clear where the committee can confirm the name, account number, and amount due on the bill. Screenshots or incomplete photos of bills will not be considered. All bills need to have the company name, account holder's name and address, and amount due.
3. Provide the first two pages of your most recent tax return document. This is required to expedite the grant process and comply with Federal tax auditing guidelines.
4. Provide a current (within 90 days) letter of treatment/diagnosis from a medical professional. This letter must be on professional letter head and include the patient's name, date, and medical professional signature.
5. Must be a U.S. Citizen or Legal U.S. Resident. All Legal Residents must attach a copy of their residence card as well as valid government issued ID.
6. The applicant may not have received $1000 from The Help Now Fund within the last calendar year
7. Applicants, please provide the Medical Release Agreement to YOUR medical professional listed on the application. Medical Release Agreements can be found here
8. Applicants, please provide the Billing Release Agreement to YOUR utility company, mortgage company, and/or leasing agency. Billing Release Agreements can be found here

Disclaimer:

DO NOT attach either the Medical or Billing Release to your application. These documents allow BCCA to retrieve basic information regarding treatment and billing. However, both are needed to complete the application selection process. Please provide these documents to the correct medical professional or company. If the applicant does not give the Medical or Billing Release documents to the appropriate party, the application may not be considered for funding. 

Patient Information

Patient Name (Nombre)
First Name
Last Name
Date of Birth (Fecha de Nacimiento)
Patient Street Address (Direccion)
Patient Email (Correo Electronico)
Patient Phone (Numero de telefono)
Please provide the date of your most recent breast cancer diagnosis

Healthcare Professional Information

* Healthcare Personnel Name (Nombre del Doctor o asistente social)
Last Name, First Name

Applicant Questionnaire

Billing Information

Address
City
State/Province
Zip/Postal
Country
If bill verification requires a passcode or PIN and the applicant does not provide it, we will be unable to consider that bill for funding.

Required Documents - Not to Exceed 7 MB

In order to be considered for funding the patient must submit all required documents. Documents must be legible, clear, and current. Screenshots and/or partial documents will not be accepted, the full bill and/letter must be submitted for consideration. The only file types accepted are .jpg,.jpeg,.jpe,.png,.pdf,.bmp. DO NOT SUBMIT ZIP FILES AS YOUR APPLICATION WILL NOT BE CONSIDERED.

Drop a file here or click to upload Choose File
Maximum upload size: 8MB
Drop a file here or click to upload Choose File
Maximum upload size: 8MB
Drop a file here or click to upload Choose File
Maximum upload size: 8MB
Drop a file here or click to upload Choose File
Maximum upload size: 8MB
Drop a file here or click to upload Choose File
Maximum upload size: 8MB
Drop a file here or click to upload Choose File
Maximum upload size: 8MB
Drop a file here or click to upload Choose File
Maximum upload size: 8MB

Share your Story!

This is the portion of the application where the patient has the opportunity to greater explain to the committee how they feel the grant will help them in their breast cancer journey.
I authorize The Breast Cancer Charities of America (BCCA) to use my words as well as
photograph me (or use provided photos of me & my family) and acknowledge that all
photographs become the property of BCCA and will be used exclusively for the
programs and advocacy efforts of BCCA.

I agree that The Breast Cancer Charities of America may also omit or selectively add
words for editorial purposes to my story as it will not change the intent of my
testimonial.

I agree that The Breast Cancer Charities of America (BCCA) may use such
photographs of me with or without my name and for any lawful purpose, including for
example such purposes as publicity, illustration, advertising, and web content.

Drop a file here or click to upload Choose File
Maximum upload size: 8MB
Before submitting your application make sure the application is completed in full. This includes: 

  • Copy of Photo Identification
  • A letter from a medical professional that was written within 90 days
  • A recent copy (within 90 days) of bills which you are seeking assistance fornt or the first and last page of your lease ***Note if the lease is out of date we will need a renewal letter stating that***
  • The medical release form has been provided to your doctor's office
  • The billing release form has been provided to the company for which you are asking assistance (utility/mortgage/leasing office/etc.) 

All applicants will be notified no later than the 15th of the month. When you successfully submit your application you will receive a message and email stating it confirming a successful submission 

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Sending

Sorry, but this form is no longer accepting submissions.

Thank you for inquiring about the help now fund, applications are open and accepted the first through the fifth of every month only. If you are inquiring about the status of an application, someone will be in touch with you by the 15th of every month with an update. Decisions will not be made until the 15th of every month. For more questions please email helpnow@IGoPink.org