Women Who Rocks the SUNCOAST
Living Waters Financial Assistance Program Application for

Sarasota, Florida Residents

Application for Individuals Undergoing Active Breast Cancer Treatment

Enter Contact Information

Full Name *

Date of birth *

Address *

City *

State *

Zip Code *

What county do you live in? *

Phone *

Email *

Treatment Verification

Type of Treatment (check all that apply): *

Surgery

Chemotherapy

Radiation

Other (please specify):*

Date of Diagnosis (MM/DD/YYYY): *

Physician's Name: *

Physician's Contact Information: *

*Attach Physician's Note Confirming Active Treatment

Household and Income Verification

Household and Income Verification *

Number of People in Household
Monthly Household Income:

Is your household income at or below 200% of the federal poverty level? *

Yes

If your family's income is at or below the amount listed for your family size, you are considered to be at the federal poverty level.

Briefly describe your current need and how assistance will help: *

Certification and Signature *

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that assistance is limited to a one-time award during a 12-month treatment period and is subject to fund availability. I authorize the Living Waters Financial Assistance Program to verify the information provided and contact my physician for treatment verification.

Signature *

Clear

Date *

Application Submission

Please submit your completed application and all required documents to:

Living Waters Financial Assistance Program

via email: [email protected] or via fax (386) 204-4139

Applications are reviewed within 48-72 hours. You will be notified of the decision as soon possible.