Safety Net of Hope Application

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$17

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Safety Net of Hope Application

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Safety Net of Hope Assistance Application

First Name

Last Name

Email

Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Household Size

Citizenship

Yes

No

At least one parent employed?

Yes

No

Employer Name

Job Title

Annual Income

Child First Name

Child Last Name

Child Date of Birth

Currently in High School?

Yes

No

Medical Condition

Hospital Name

Admission Date

Days Hospitalized

Expected Recovery Time

Insurance

Yes

No

Coverage Details

Receiving Government Aid?

Yes

No

Receiving Charity Aid?

Yes

No

Describe Financial Hardship

Why current support is insufficient

Type of Assistance

Rent

Utilities

Food

Transport

Other

Amount Requested

Referred by medical professional?

Yes

No

Referrer Name

Referrer Contact

By checking this box, you confirm that all information submitted is true and correct.

Agree to follow-up assessment

Yes

No

Digital Signature

Submission Date

27

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On Publication 78 Data List: Yes
Deductibility Code: PC
Section 501(c)(3) Status

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