Application for Assistance

THE GOOD NEIGHBOR FUND

ST. PARASKEVI GREEK ORTHODOX CHURCH

1 Shrine Place, Greenlawn, NY 11740

ALL INFORMATION IS STRICTLY CONFIDENTIAL

Personal Information

First Name *

Last Name *

Date of Birth: *

Address 1 *

City *

State *

Postal Code *

Home Phone *

Cell Phone: *

Email Address *

Name of Social Worker/Organization who referred you. *

Social Worker's email *

Contact person to discuss your case: *

Contact person's phone number: *

Name of medical insurance: *

Patient's Doctor's Name *

Are you receiving financial assistance from other organizations/agencies? *

Yes

No

If yes, please list in detail. *

Are you currently employed? *

Yes

No

If yes, please list employer and contact phone number. *

Have you applied for assistance from the Good Neighbor Fund before? *

Yes

No

If yes, list date of award: *

List amount of reward: *

Describe your present health situation and why you are seeking financial assistance: *

0/500 characters

Describe the purpose of/ amount you are applying for in order of priority in the spaces below, from most to least important. Enter "n/a" in the spaces not needed and "0" in the amount fields not needed.

*

Amount *

*

Amount *

*

Amount *

*

Amount *

GNF prefers to pay bills that are in applicant's name. If bill is not in applicant's name, please explain relationship to bill holder. Enter "n/a" in not applicable. *

Is the payee name, address and account number on the bill? *

Yes

No

If no, please provide payee's name, address and account number. If yes, enter "n/a". *

Have these bills been submitted to any other organization? *

Yes

No

If yes, please provide the name of organization(s), amount and date. If no, enter "n/a". *

Please answer all questions or your application will not be accepted. You will be notified once your case is reviewed.. Please note that all bills will be verified prior to payment and that GNF does not pay directly to individuals.

GNF requires the following documentation to be submitted with application:

A signed letter from a doctor on his/her letterhead confirming diagnosis.

A signed letter from a hospital social worker or 501C3 Administrator verifying that applicant has been screened and qualifies for financial assistance.

A current copy of bill to be paid dated within 30 days of application. Please include name, address and phone number of the Company to be paid and account number.

If requesting rent or mortgage payment, please be sure to include a lease or legal binding document from your landlord or a current mortgage statement.

By signing this application, you are certifying that the information and statements contained(including any other material and information submitted) are true and correct and that you give the GNF permission to contact a payee should we have additional questions.

Signature: *

clear

Name *

Please indicate the date of this application: * +