Financial Assistance (Please Allow 24-48 Hours For A Response)
RequiredRequired Question(s)
Required 1.
Full Name
 

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Required 2.

Address 

 

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Required 3.

Phone Number 

 

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4.
Email
 

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5.
Please check below the reason(s) you're needing emergency assistance.
Illness
Car Accident
Loss of Job
Other  
When applying for this service, please note: this is only for cancer survivors, caretakers, and family members caring for those battling cancer.  
 
Required 6.
Do you need assistance with the following household expenses? 
Please write monetary amount next to each selection.
Energy (Light & Gas)
Water
Telephone (Landline or Cell)
Food
Rent
Other  
7.

Financial Assistance continued.

Please write monetary amount next to each selection. 

Personal Care
Prescription or Medical co-pay
Car Insurance Premium (one month)
Car loan payment (one month)
Vehicle Registration (one month)
Other  
8.
Financial Assistance continued.
Please write monetary amount next to each selection.
Day Care Expenses (one month)
Clothes for Employment
Tools for Employment
Gas/other transportation.
Other  
9.
Have you received a shut-off or demand for payment notice?
Please Explain.
Yes
No
Other  
Required 10.
Please list all monetary amounts and account #'s associated with each request.
 

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Required 11.
Please read and type name and date below to show that you agree and understand all statements.
I, certify that the information I have given is correct and complete to the best of my knowledge. I understand that benefits received upon false information must be repaid and can result in my exclusion from receiving emergency assistance from Imagine Me Foundation. in the future. I give Imagine me Foundation permission to verify my information provided in regards to my accounts and that can affect my eligibility to receive funds.
 

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