Are you currently undergoing active treatment (surgery, chemotherapy, and/or radiation)?
Please describe your treatment plan, if so
Length of treatment:
(include specific dates and timeframe)
Have you received assistance in the past 12 months from other charitable organizations, churches, etc?
Please describe your request for assistance with household bills in detail and outline your need:
(Include amounts of any past due bills. Medical bills are not an expense covered through The Meggs Foundation)
Please describe how the onset of your medical treatment has impacted your ability to pay your bills:
(Lost wages, limited ability to work, poor insurance coverage, etc.)
Assistance Request / Applicant Statement / Release / Affirmation
I do agree to release to The Meggs Foundation II, Inc. (“The Meggs Foundation”) or its duly authorized representative, any information deemed necessary to complete its investigation of my application for financial assistance and as may be reasonably required to assist myself and my family. As an inducement to The Meggs Foundation to consider supplemental financial support in conjunction with the medical treatment of the applicant named above the undersigned does hereby affirm as follows:
1. The term “non-medical expenses” is understood to mean those reasonable and necessary expenses incurred by the family of the above-named Applicant or the above-named Applicant, in conjunction with that Applicant receiving medical treatment. Financial assistance will be provided, with the use of said funds to be specified by the Meggs Foundation. Bills cannot be in another person’s name or be on an automatic payment system with creditor.
2. Please provide the following supporting documents for assistance requested:
Copy of driver’s license or state identification card.
Proof of eligibility; a letter from your doctor advising that you are receiving treatment for a specific illness.
Copy of bills to be paid (please submit a photocopy of the invoice to ensure payment is attributed to the correct account). Bills must be in the patient or spouse’s name.
Photocopy of Bank statements from all adults residing in the household (3 months).
Photocopy of most recent Federal Income Tax Return and W2 for all members of the household.
Photocopy of last pay stub.
Photocopies of current rental agreement or Lease (only for those requesting assistance for rent).
*Payments made for patients may require an IRS form W-9 to be completed by The Meggs Foundation. The Meggs Foundation will pursue restitution for grants if it is determined that the information submitted on the application is false.
The Meggs Foundation will pursue restitution for grants if it is determined that the information submitted on the application is false.
I have read the guidelines for financial assistance and I declare that the information furnished on this application form, including attached sheets, is true and correct to the best of my knowledge.
For good consideration which I acknowledge, I irrevocably grant to The Meggs Foundation II, Inc., ("The Meggs Foundation") and/or its subsidiaries, affiliates, representatives, assigns, licensees, and/or successors the right to use my story, my name, artwork, photographs, audiotapes, and/or letters that I provide of my child, my family, or myself in publications, slides, videotapes, motion pictures or on the internet, and in all forms and media including composite or modified representations for all purposes, including advertising, charitable solicitations, trade, or any commercial and/or charitable purpose throughout the world and in perpetuity. I waive the right to inspect or approve versions of any of the above listed used for publication or the written copy that may be used in connection with any images. The Meggs Foundation is permitted, although not obligated, to include my name as a credit in connection with any images. I understand any visual images, story, letters or recordings may be primarily used to inform families, volunteers, donors, the media and general public about The Meggs Foundation programs, services, fundraising efforts, or events. I gladly give this authorization to support the efforts of The Meggs Foundation. I understand this authorization shall continue unless terminated in writing by The Meggs Foundation. I release The Meggs Foundation and The Meggs Foundation’s subsidiaries, affiliates, assigns, licensees, directors and successors from any claims that may arise regarding the use of my image, including any claims of defamation, invasion of privacy, or infringement of moral rights, rights of publicity, or copyright. The Meggs Foundation is not obligated to utilize any of the rights granted in this Agreement.