Housing Expense Assistance Application

Housing Expense Assistance Application
OUR MISSION: To financially and resourcefully support Arizona families who endure financial hardship while experiencing extended illness or injury of their children. The Care Fund provides mortgage or rent support during a child's extended health crisis.
Important Notes : Completed applications & supporting documents are accepted by Email (info@thecarefund.org), Fax (480.223.6311), Mail or via Online Submission. All information provided is subject to review and verification. Medical Certification must be provided and verified before a submitted application will be considered. May be sent by various methods listed above. For questions, please contact the Care Fund office by phone (480.305.8611) or by email (info@thecarefund.org). For approved applicants, the Care Fund does not expect repayment in any form. Payment for approved applications will be submitted directly to the mortgage lender or the landlord/lessor.
Care Fund Contact Information: Address : 16427 N. Scottsdale Road, Suite 145, Scottsdale, AZ 85254 Phone : 480.305.8611 Fax : 480.223.6311 Web : www.thecarefund.org Facebook : www.facebook.com/CareFundOrg

FAMILY & MEDICAL INFORMATION
Child's Name (affected by illness or injury): *
Child's Date of Birth: *
Names & ages of other individuals living in your home. Please include all adults and children. *
We are residents in the State of Arizona *

YES NO
Care to Share? The Care Fund would like to know more about you and your family! Please utilize this section to tell us more about each member of your family; including interests, hobbies, accolades, awards and activities. If you'd like to attach photos or memorable moments captured on video, please feel free to include those when submitting your application. *

0/1500
Child's Medical Situation: Please write a description of your child's medical situation to include: 1. Type of illness or injury 2. Diagnoses 3. Length of hospitalization 4. Type of treatment 5. Number of surgeries 6. Other supporting medical information. Please remember that a medical certification and verification is required to successfully complete your application. Your child's medical care provider or the hospital social worker must provide this verification directly to the Care Fund. *

0/1500
Please provide the dates of your child's hospitalization, home care and/or treatment(s): *

0/1500
Child has had: (check all that apply) *

Inpatient hospital care Full-time home care Hospice Care Rehabilitation Extended treatment
Doctor's Name: *
Doctor's Office or Hospital *
Doctor's E-mail: *
Doctor's Phone Number: *
Insurance or medical coverage provider: *

ADDITIONAL SOURCES OF HOUSEHOLD INCOME
Please indicate the amount and frequency of additional income received below.
Social Security/Social Security Disability
Child Support/Alimony
Foster Care
Pension/Retirement
Food Stamps
Unemployment/Workers Compensation
Other Public Assistance
Grants
Other Non-Profit Organizations (provide name and amount received)
Other
HOUSEHOLD OBLIGATIONS & LIABILITIES
Please list the monthly payment for all household obligations and liabilities below.
Mortgage Payment
Rent Payment
Car Payment
Groceries
Car Payment
Gas/fuel
Car Insurance
Medication/Prescriptions
Cable/Internet/Phone
Health Insurance
Cell Phone(s)
Medical Co-Pays
Child Care
Dental/Vision
Child Support/Alimony
Other Out-of-Pocket Medical Expenses
Student Loan(s)
Un-reimbursed Business Expenses
Utilities (Power)
Credit Card Payments
Utilities (Gas)
Attorney/Legal
Utilities (Water/Sewer/Trash)
Healthcare Related Travel
Other
Other
Other
Other

HOUSING EXPENSE INFORMATION
Please include a copy of your most recent mortgage statement, verifying your account number, property address and mortgage payment OR a copy of your current lease agreement and landlord contact information. *Please note that for approved applications, payment will be submitted directly to the mortgage lender or the landlord/lessor.
Name of primary mortgage lender OR landlord/property manager/lessor *
Payment Address: *
Contact Name, Phone Number & Email Address (if available): *
Monthly Payment Amount: *
Account Number (if applicable)
Name(s) on mortgage or lease: *
For a second mortgage, please provide the same information below & attach a statement.
Are you current on your mortgage or rent payments? *

YES NO*
*If no, how far behind are you?
Are your mortgage or rent payments automatically withdrawn from your bank account? *

YES* NO
If yes, what day of the month are funds withdrawn from your account for payment?
If your have not lived in your current residence for more than 2 years, please also provide prior mortgage payment and name of mortgage lender OR prior lease agreement and property contact information.
HOUSING EXPENSE AUTHORIZATION
I/We hereby authorize the mortgage lender or landlord listed above to provide the status of my/our mortgage loan (loan number stated above) or my/our lease to the Care Fund or their designated representative. Selecting "I authorize" or "We authorize" below signifies my/our authorization. *
Please enter your name(s) as your electronic signature:
Please enter today's date: *

Month Day Year
Date

ASSETS
Vehicle (Year/Make/Model)
Vehicle Value
Vehicle (Year/Make/Model)
Vehicle Value
Selecting "I authorize" or "We authorize" below signifies my/our authorization.
Primary Residence (Address)
Residence Value
Additional Residence (Address)
Residence Value
Bank Account Balance
Bank Account Balance
Bank Account Balance
Bank Account Balance
401k/Retirement Account Balance
Other Savings Balance
Other (Watercraft, RV, etc)
Stocks/Bonds/CD"s
Other
Other
Work & Financial Impact: Please use this space to provide details regarding the financial hardship experienced by your family. Please make sure to describe your experienced loss of income or assets (due to unpaid leave from work, decreased work hours, loss of job, etc) as a result of your child's hospitalization, injury, medical treatment or home care. Please also describe details of additional expenses incurred (mileage, meals, parking, gas, lodging, travel expenses, etc), increased out-of-pocket insurance payments, prescription costs or other medical expenses. *

0/1500

APPLICATION AUTHORIZATION
By selecting "I AUTHORIZE/WE AUTHORIZE" below, I/We affirm and agree that: I/We have read the guidelines and understand them. I/We attest this information is true to the best of my/our ability. I/We authorize my/our child"s medical care provider to discuss my/our child"s medical information pertinent to this case with the Care Fund or their designated representatives. I/We understand that if approved for assistance, the Care Fund does not expect repayment in any form. I/We grant permission to the Care Fund to obtain and verify all necessary information in order to process this application. This information includes, but is not limited to, my/our past and present consumer credit record, mortgage or rental record, income or employment, expenses, dependents, etc. I/We understand that if approved for assistance, mortgage or rental payments may be made on our behalf directly to the mortgage lender or landlord/lessor.
Please enter your name(s) as your electronic signature: *
Please enter today's date: *

Month Day Year
Date
RELEASE
The Care Fund hopes to help as many families in our community as possible. By sharing your story, we will be able to expand our reach within our community. We promise to share your story with the highest integrity, with your permission only. We may request photos, testimonials and/or appearances.
Please select from below: *

I/We give the Care Fund consent to use our family Use our story, however please keep our family anonymous. (Please complete both drop-down sections below.) Do not use our story.
Please enter your name(s) as your electronic signature: *
Please enter today's date: *

Month Day Year
Date
IF AUTHORIZING THE RELEASE, PLEASE COMPLETE BOTH SECTIONS BELOW:
I/We understand that neither my child nor I/us will receive any compensation as a result of the use of our information and photos as described in this release. I waive any rights of privacy and/or approval of the materials in which our name and/or likeness may be used. Selecting "I agree" or "We agree" below signifies my/our agreement and acknowledgement of the above statement. *

I AGREE WE AGREE
Please enter your name(s) as your electronic signature:
Please enter today's date:

Month Day Year
Date
I/We hereby grant the Care Fund permission without restriction to use in all media my child's name and photo, and my/our name and photo, as well as the story of my child's illness, injury and/or treatment, to promote the purposes of the Care Fund and to solicit funds to help other children. Selecting "I agree" or "We agree" below signifies my/our agreement and acknowledgement of the above statement. *
Please enter your name(s) as your electronic signature: *
Please enter today's date:

Month Day Year
Date

APPLICATION CHECKLIST
Most recent mortgage statement or lease agreement provided.

Yes No
I/We have signed off on all parts of the application.

Yes No
I/We have provided our most recent 2 paystubs from any income sources.

Yes No
I/We have contacted our child's medical provider or hospital social worker, to complete the medical certification form.

Yes No
WHAT'S NEXT?
Our team will begin to review and verify the information provided in your application as soon as we receive the following: - Completed application, with all pertinent information provided. We will contact you if any information appears to be missing, as it may impact or delay our decision making process. Providing the requested information in a timely fashion will help to expedite our process. - Please send supporting documents by fax, email or mail. - Medical certification submitted or provided by your child's medical provider or hospital social worker. Please make sure you have provided accurate contact information for your child's Doctor or social worker, so that we may send the certification to them. - Most recent paystubs for any income sources. - Most recent mortgage statement or lease agreement provided, with all pages.

- Most recent bank statements for all accounts noted on application.
Our review process consists of the following steps: - Verification of all information provided in your application. This may be done verbally or in writing. This may include, but is not limited to: employment and/or income verification, mortgage or rent verification, past and present consumer credit record, etc. - Verification of eligibility based on our current giving guidelines. Guidelines can be found at www.thecarefund.org - Verification of medical certification. This may be done verbally or in writing. - Once all verifications are complete, our review committee will meet to determine whether assistance will be provided and approved. - Approval of an application is made at the sole discretion of the Care Fund. Approval is made on a case-by-case basis, based on available funds. - You will be contacted by a member of our team, to inform you of the review committee determination. If you are awarded assistance, they will also review the parameters and time frame with you.
THANK YOU! - From the team at the Care Fund
Should be Empty: