Apply for Assistance

Do you or someone you know need help?

Assistance Application

To apply for financial aid intended primarily for people in Connecticut from Amy’s Angels Corporation, please complete this Application for Assistance and sign where indicated (for mailed/scanned copies). If you need additional help, please call 860-919-9276.

Use the form below to complete your application, or email scanned copies to info@amysangels.org. Printed copies can be mailed to Amy’s Angels, 90 Hopmeadow Street, Weatogue, CT 06089

Download the PDF Application

Assistance Request

Amount Requested (Estimate) *

Patient Information

Patient Full Name *

First

Last

Patient's Date of Birth *

Patient's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient's Phone Number *

Patient's Email *

Is the patient a U.S. Resident? *

Patient's Gender *

Male
Female

Diagnosis: *

Date of Diagnosis:

Physician/Service Provider:

Treatment Center:

Source of Referral to Amy's Angels:

Family Information

Primary Contact: *

Mother
Father
Guardian
Other

Primary Contact's Full Name *

First

Last

Primary Contact's Phone Number: *

Primary Contact's Email Address:

Insurance Coverage: *

Private Insurance
Medicare
None

Provider Name: *

Are prescription drugs covered? *

If yes, please describe any limits on the prescription drug coverage: *

Please describe your family’s medical and financial situation. We seek to understand what financial consequences you/your family are experiencing as a result of your illness/injury and the actions being taken to regain financial stability. Please comment on expected outcome of the treatment plan: *

Type of aid you are seeking: *

Estimated Monthly Family Expenses

If not applicable or unknown, please type n/a or unknown in the field.

Rent/Mortgage: *

Utilities/Phone: *

Childcare:

Medical: *

Food: *

Transportation: *

Other ongoing expenses: *

Total monthly expenses: *

Estimated Monthly Family Income

If not applicable or unknown, please type n/a or unknown in the field.

Wages after withholdings: *

(i.e., take home pay)

Unemployment:

Disability:

Public Assistance:

Social Security:

Other Sources:

ie: alimony, child support, etc.

Total monthly income: *

Net monthly income:

Current Financial Information

Please include a copy of the most recent paystub from each employer for whom you and/or a member of your family is employed:

Click or drag a file to this area to upload.

Please upload a PDF copy of your most recent Tax Return

Click or drag files to this area to upload. You can upload up to 3 files.

If you do not have a copy ready to attach, please email a copy to info@amysangels.org as soon as possible.

Have you received any financial assistance from any organization since the diagnosis? If so, please explain:

Available Cash & Savings: *

List approximate totals, not account numbers.

Investment Accounts:

List approximate totals, not account numbers.

Retirement Accounts:

List approximate totals, not account numbers.

Approximate Net Worth:

Signature & Acknowledgment

I hereby verify and affirm that the contents of this Grant Application are truthful, accurate and complete to the best of my knowledge and belief.

Applicant/Parent/Guardian Signature: *

Please type your full name. By typing your name above you are agreeing to the Signature & Acknowledgment statement.

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Name *

First

Last

Email *

Apply for Assistance

Assistance Application

Assistance Request

Patient Information

Family Information

Estimated Monthly Family Expenses

Estimated Monthly Family Income

Current Financial Information

Signature & Acknowledgment

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