The Hospice Promise Foundation Board of Directors (BOD) requires the completion of this form for submission and approval of a grant request. Verbal communication with any
member(s) of the BOD or their representatives shall not substitute for submission of this form. Each space must be complete.
The Hospice Promise Foundation Mission Statement
The Hospice Promise Foundation's mission is to assist persons in hospice care and their families
with essential, non-hospice related expenses that they are unable to afford themselves.
The Hospice Promise Foundation is a non-profit organization funded by donations from grateful
patients, families and friends of our patients and is governed by the Board of Directors.
Applicant Information
An asterisk (*) denotes a required field
Description of Request
* If requesting utility or any payments for which there is an account and account number,
please attach documentation indicating the account holder’s name and account number. In
some circumstances, the account holder’s SSN may be requested by the HPF in order to apply
the grant payment to the proper account.
Please check one of the checkboxes below for the description of the request.
Financial Needs Assessment
Please provide any of the following items that are applicable in order
to confirm grant recipient’s household monthly income AND reserves.
This documentation must be attached to grant request forms.
Most recent Federal / State income tax forms
Unemployment check stubs/paycheck ( 3mths)
Statement of monthly benefits from SS
Life insurance policy
Documentation of other investment accounts
W-2 withholding statements and/or 1099
Copy of proof of pension amount
Approval/Denial forms of public aid, unemployment, and documentation worker’s compensation
401k/Retirement account balance
Regular savings and/or checking acct balance
TOTAL PERSONS IN FAMILY OR HOUSEHOLD*
Based on grant recipient’s income and applicable family or household size,
please select the current number of individuals living in the household
Please specify the number of persons in the family or household.
Add $896.67 for each person over 8
PATIENT ATTESTATION: This is to advise that I have pursued all other avenues possible, including private insurance, governmental and charitable
agencies providing funding and relief from financial obligations as well as public aid. Therefore, I hereby request that The Hospice Promise
Foundation make a determination of my eligibility for grant assitance. I understand that the information, which I submit concerning my annual
income, family size and asset reserves, is subject to verification by The Hospice Promise Foundation
Upload Documents*
You must upload supporting documentation.
Procedure for Completed Application
All completed Request for Foundation Support Forms should be accompanied by a Financial Needs Assessment Form and are subject to limits established by the Foundation
guidelines. Requests will be sent to The Hospice Promise Foundation Board for review. A representative of the Foundation will contact you within 72 hours of receipt. If request
for funds is emergent, an answer will be sent within 24 hours of receipt. The Foundation, as a non-profit entity, may require a follow-up report to verify the donation was spent in
accordance with this request. Please designate the individual(s) responsible for submitting a follow-up report and supplying the requested information.
