Instructions for Completing the StringsforaCURE® Living Expense Grant Application StringsforaCURE® is an Erie, PA based 501(c)(3) non-profit charitable organization, founded by Elisa Guida, a two-time breast cancer survivor, as her way of giving back to the breast cancer community. We are dedicated to providing education, comfort, support and financial assistance directly to cancer patients, primarily those with breast cancer. The StringforaCURE Foundation is an independent non-profit, charitable organization and is not associated with American Cancer Society, CancerCare, or any other organizations, health systems, hospitals or cancer centers. The funding for the StringsforaCURE programs is provided by the generous donations of our supporters, mostly in Erie and the Northwestern Pennsylvania Region. Our Living Expenses Grant program provides a one-time Living Expenses grant to breast cancer patients living within a 60-mile radius of Erie, PA based on financial need to help ease the financial burden during the patient’s breast cancer journey. Eligibility Criteria:  Applicant must be a breast cancer patient who is a U.S. citizen and permanent resident of the U.S. and a full-time resident who lives within a 60-mile radius of Erie, PA.  Patient must complete and submit a Living Expense Grant application, including all required information, documentation and signatures.  The grant is awarded based on financial need. o Income guidelines are not disclosed. o Eligibility is determined on a case-by-case basis. o Supporting documentation may be submitted as a proof of extenuating circumstances.  All bills submitted for consideration must include the breast cancer patient’s name on the account.  The award period for the grant is July 1- June 30 with budget reevaluation at the beginning of each fiscal year.  The maximum amount of the grant awarded is up to $1,500 per person.  If you have applied for and received a Medical Assistance Grant from StringsforaCURE, you are not eligible to apply for a Living Expense Grant. Allowable Expenses: The grant is for use only on the following types of expenses:  Mortgage - the mortgage bill must include the breast cancer patient’s name on the account.  Rent Payments - a current lease which includes the breast cancer patient’s name must be submitted.  Car Payments – the car payment bill must include the breast cancer patient’s name on the account.  Car Insurance Payments – the car insurance bill must include the breast cancer patient’s name on the account.  Utility (Gas, Electric, Water, Sewer, Refuse) Payments – the utility bills must include the breast cancer patient’s name on the account.  Health Insurance Premium Payments – the health insurance bill must include the breast cancer patient’s name or the breast cancer patient must submit a copy of his or her insurance card. This grant is for living expenses only, such as rent, mortgage, utilities, and insurance payments, NOT for medical, gas, grocery or pharmacy expenses or non-essential living expenses, such as phone, cable, Direct TV, etc.

Payment of Grant: If a patient’s grant application is approved, payment will be made directly to the patient’s creditors on behalf of the patient. We do not reimburse the patient for payments already made. The breast cancer patient will be required to submit a story or statement about how the patient benefited from the StringsforaCURE Living Expense Grant with an option to have a photograph taken at the discretion of the SFAC Board of Directors. The information will be used by StringsforaCURE to publicize how patients benefit from these grants. In order for StringsforaCURE to make a payment to a creditor, the following must be provided with the application:  Total amount of financial assistance requested  The original bill(s) from the creditors, (such as a mortgage company, rental agency, car loan and/or insurance company, utility provider, health insurance provider.) with the amount due from the creditor(s) listed above all of which must include the breast cancer patient’s name on the accounts.

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PLEASE FOLLOW THE INSTRUCTIONS ON THE FOLLOWING PAGES TO COMPLETE THIS APPLICATION. SECTION I - PATIENT INFORMATION Please complete all demographic and contact information, including name, birthdate, address, phone numbers and email address. It may be necessary for StringsforaCURE to contact you regarding your application.

SECTION II - HEALTHCARE PROFESSIONAL INFORMATION Please complete the healthcare professional contact information, including name, hospital or clinic, address, and phone and fax numbers, for the physician treating your cancer, such as an oncologist, radiologist or surgeon. (This is not your primary care physician’s information.) Under “Diagnosis Information,” include the type of cancer, stage and date of diagnosis and whether this is a new diagnosis or a recurrence and if you are in active treatment. Under “Healthcare Provider Information,” print the name and phone number of the health care provider who is verifying your diagnosis and indicate whether the health care provider is a physician, nurse or social worker. The application must be signed by this Healthcare Provider.

SECTION III – HOUSEHOLD FINANCIAL INFORMATION This section is a means of determining the patient’s financial need. Please complete this section carefully and in its entirety including the required documentation. Indicate the number of people living in the household, whether the patient is currently employed, and if so, where. Under “Family Income Sources,” indicate all of the patient’s sources of income as well as the total household income. Under “Family Assets,” indicate the total value of any of the assets listed. Under “Required Financial Documentation,” specify the type of required and supporting documentation that is being included with the application. *The patient’s tax return along with a W-2 statement is required. If the patient is on Social Security, the patient’s tax return and Social Security statement are required. Other supporting documents may also be submitted. *The application will not be processed without this financial information and documentation.

SECTION IV – FINANCIAL ASSISTANCE REQUESTED This section specifies the type of financial assistance that is being requested and is very critical to the review and approval of this living expense grant application.  Check the box next to the item(s) that apply to the patient’s financial assistance request.  Include the original bill(s) from the creditors, (such as a mortgage company, rental agency, car loan and/or insurance company, utility provider, health insurance provider) and the amount due to the creditor(s) along with the application.

SECTION V – PATIENT VERIFICATION OF INFORMATION Please check each box acknowledging that you have read and agree with each statement. By signing the application, you, the patient, are verifying that all of the information is truthful and accurate. Any information that has been knowingly falsified could be considered an act of fraud and will be addressed accordingly. You are also giving StringsforaCURE authorization to check with the creditors for which you submitted bills that the bills are accurate and have not already been paid. NOTE: All sections must be completed and all requested information must be provided. Incomplete applications will not be processed!

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Questions about this application can be directed to Nicole. Email: [email protected]

Mail completed application and required documentation to: StringsforaCURE P.O. Box 9823 Erie, PA 16505 ATTN: LE App

All applications must be mailed. Applications received electronically will not be processed. We recommend that you make a copy of your completed application for your records before mailing the application in the event that any questions arise.

Before mailing, please use the checklist below to ensure that your application is complete. This will help to ensure that your application will be processed as quickly as possible! If your application is incomplete or missing information, your application will not be processed. HAVE YOU COMPLETED THE ENTIRE APPLICATION? Patient Information – Ensure that contact information complete and legible. Physician Treating Cancer – Ensure that the Contact Information for your physician is complete. Diagnosis Information – Diagnosis, Diagnosis/Recurrence Date, and Type of Active Treatment must be complete. Healthcare Provider Information Verifying Diagnosis – Contact Information for your healthcare provider must be complete. Healthcare provider verifying the diagnosis must sign/date the application. Household Financial Information - Ensure that all questions have been answered and the Total Annual Household Income is filled in. Financial Assistance Requested - Ensure that you have indicated the type of Living Expense assistance being requested and the TOTAL AMOUNT of financial assistance being requested. Have you signed and dated the Application? HAVE YOU SUBMITTED THE REQUIRED FINANCIAL DOCUMENTATION? Required financial documentation is being submitted: Tax Return and W-2 Form Tax Return and Social Security Statement HAVE YOU SUBMITTED THE COPIES OF THE BILLS FOR WHICH YOU ARE REQUESTING PAYMENT? Copy(ies) of the bills from each of the creditors that you wish to be paid. The bills must include the breast cancer patient’s name on the accounts.

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StringsforaCURE® is an Erie, PA based 501(c)(3) non-profit charitable organization, founded by Elisa Guida, a two-time breast cancer survivor, as her way of “Giving Back” to the breast cancer community. We are dedicated to providing education, comfort, support and financial assistance to cancer patients, primarily those with breast cancer.

StringsforaCURE® Living Expense Application The StringsforaCURE Living Expenses Grant Program is intended to provide financial assistance for living expenses to breast cancer patients. Applicant must be a full-time permanent resident of the U.S. living within a 60-mile radius of Erie, PA. SECTION I - PATIENT INFORMATION

Application Date ____________________ Last Name _________________________ First Name________________________ Date of Birth ______________ Street Address_________________________________________________________________________________ City, State, Zip _________________________________________________________________________________ Home Phone (____)____________________ Cell Phone (____)____________________ May we leave a message?

Yes

No

May we leave a message?

Yes

No

E-mail Address______________________________________________________________________ SECTION II - HEALTHCARE PROFESSIONAL INFORMATION

Physician Name _______________________________________________________________________________ Hospital/Clinic ________________________________________________________________________________ Address ______________________________________________________________________________________ Phone (____)____________________________ Fax (____)____________________________ ********************Diagnosis Information********************* Primary Cancer ____________________________________ Stage _________ Diagnosis Date ______________ This diagnosis is: New Recurrence In active treatment? Yes No ********************Treatment Information********************* Please indicate the type of treatment(s) received in the past twelve months: Chemotherapy Radiation Hormonal Surgery Palliative care Physical therapy Bone marrow/stem cell ******************** Healthcare Provider Information********************* Printed Name _____________________________________________ Phone (____) ______________________ E-mail Address (Required) _____________________________________________________________________ Relationship to patient:

Physician

Is this treatment medically necessary?

Nurse Yes

Social Worker No

Signature ____________________________________________________ Date_____________________ NOTE: Application must be signed by the Healthcare provider verifying the diagnosis information. Application will not be processed without the signature of the health care provider.

SECTION III – HOUSEHOLD FINANCIAL INFORMATION

Marital Status: Single Married Divorced Widow Number of people currently in household: _______________ Explain relationship(s) to patient____________ __________________________________________________________________________________________ Is the patient currently employed: Yes No If yes, place of employment: __________________________________________________________________ Are other people in household employed? Yes No Are they responsible for paying any of the household or medical expenses? Yes No Please explain: ______________________________________________________________________________ ******************** Family Income Sources********************* Please check all that apply: Employment Income Social Security Public assistance Short-term disability Support from family/friends

Pension Unemployment Social Security Disability Supplemental Security Income Other-specify______________________________________

Total Annual Household Income: ******************** Family Assets********************* Please indicate the total value of each asset that applies: Checking/Money Market:

Savings/CD:

IRA/403B/401K:

Stocks/Bonds:

******************** Required Financial Documentation********************* Please indicate the type(s) of required and supporting documentation* being provided. Check all that apply. REQUIRED Documentation: Tax Return AND W-2 Form OR Tax Return AND Social Security Statement (FOR PATIENTS WHO ARE ON SOCIAL SECURITY) Other supporting documentation that may be included: Paycheck Stub Bank Statement Disability Income Statement Retirement Account Statement Other: ____________________________________________________ *Please be sure to include the specified documentation with this application. This Living Expense Grant Application will not be processed if this information is not provided. SECTION IV – FINANCIAL ASSISTANCE REQUESTED

(REQUIRED) Please indicate the type and amount of assistance that is being requested with this application: Mortgage Payment - Amount Requested:____________ Rent Payment - Amount Requested:____________ Car Payment - Amount Requested:____________ Car Insurance Payment - Amount Requested:____________ Utilities Gas (Heating) - Amount Requested:____________ Electric - Amount Requested:____________ Water - Amount Requested:____________ Sewer - Amount Requested:____________ Refuse (Trash) - Amount Requested:____________ Health Insurance Premium - Amount Requested:____________ Total amount of assistance requested: Please attach a copy of the original bill(s) from the creditors indicated above. Applications will not be processed without these bills being submitted with the application. The bills being submitted for payment need to be in the applicant’s name or be jointly held by the applicant and another person (i.e. mortgage). 2

SECTION V – PATIENT VERIFICATION OF INFORMATION

As the patient, I understand that by signing this application I agree with the following (please check each box acknowledging the statement): The information provided above is truthful and accurate to the best of my knowledge. I authorize StringsforaCURE to contact me or my healthcare provider to verify any of the above information and/or bills submitted for payment. I authorize StringsforaCURE to contact me my creditors in order to inquire about the bills submitted for payment through a grant and/or to make the payment to the creditor. If there are other members of the household contributing to the payment of living expenses, StringsforaCURE reserves the right to request financial documentation from those household members. Approval of a patient’s application for a StringsforaCURE Living Expense is based on meeting the specified eligibility requirements. Funding for Living Expense grants is limited and based on availability. Approval of this living expense grant application may take 8-10 weeks from receipt. I agree to submit a story or statement about I have benefited from the StringsforaCURE Living Expense Grant with an option to have a photograph taken at the discretion of the SFAC Board of Directors.

Signature _________________________________________________ Date_____________________ (Patient Signature)

*********************************************************************************************** PLEASE NOTE: Please print CLEARLY. All sections must be completed. All required documentation must be attached. Incomplete applications and applications that are illegible will not be processed.

*********************************************************************************************** Please direct any questions related to this application to Nicole: E-mail: [email protected] Please mail completed application and all required documentation application to: StringsforaCURE P.O. Box 9823 Erie, PA 16505 ATTN: LE App All applications must be mailed. Electronic applications received via email will not be processed. Incomplete applications or applications without the required documentation will not be processed. We recommend that you make a copy of your completed application for your records before mailing the application in the event that any questions arise. Before mailing, please make sure that the following has been done: All sections of the application have been completed. The required financial documentation is included. (Example: Tax Return and W-2 or Tax Return and Social Security Statement) Total amount of financial assistance in Section IV is filled in. Copy(ies) of the bill(s) from the creditors to be paid is(are) included. Healthcare provider has signed the application in Section II. Patient has signed the application in Section V. *********************************************************************************************** The StringsforaCURE Foundation adheres to the following policies when processing Living Expense Grant applications:  All applications, and the information contained therein, shall be strictly confidential.  StringsforaCURE® Board reserves the right to verify all information provided to ensure all resources are distributed without discrimination as to age, race, sex or creed and shall comply with all State and Federal laws related thereto.  An application may be put on hold, pending the availability of funds.  Any information that has been knowingly falsified could be considered an act of fraud and will be addressed accordingly. 3