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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


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.
# Persons
Max Monthly Income



# Persons
Max Monthly Income



Add $856 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.