Request For Assistance & Release
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Please Print This Form To Complete.
INSTRUCTIONS: Please read the WeAreAlive 'Assistance' page on this website for assistance guidelines. A complete and valid application under the guidelines saves time in processing the request. Print this form and complete. Please print clearly. If the print out is more than one page long, be sure to sign the bottom of all pages. If you have a case worker helping you with this package, give the completed form to him or her to submit for you. If you do not have a case worker, then submit this form with the required attachments to WeAreAlive. If you have a scanner, you can scan the documents and email them to requests@WeAreAlive.org. If you do not have access to a scanner, you can mail the documentation to We Are Alive, Inc., 14427 Brook Hollow, #165, San Antonio, Texas 78232. (Note: Processing takes longer when the documentation is mailed.) If you need help completing this form, please email your questions to requests@WeAreAlive.org.
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Last Name:_____________________ First Name:___________________ MI:_____
Address:_____________________________________________________________
City:____________________________ State:___________ Zip:________________
Home Phone:(____)____-______ Fax Number:(____)____-______
Cell Phone:(____)____-______ Pager:(____)____-______
Work Phone:(____)____-______ Extension #:______ Work Hours:______-______
Email Address:____________________________@_________________________
Social Security #:_____-____-_______ Birth Date:___/___/___ (month/date/year)
Valid Picture ID #:________________ ID Type:_____________ Issuing State:_____
Do You Have A Social Worker? _¯Yes _¯No
...If Yes: Name:_____________________ Agency Name:_____________________
...........Agency Phone #:(____)____-______ Extension #:______
...If No: Why don't you have a social worker?
..........._____________________________________________________________
Primary Assistance Amount Requested:$_________ Describe Request Below:
___________________________________________________________________
___________________________________________________________________
Secondary Assistance Amount Requested:$_________ Describe Request Below:
___________________________________________________________________
___________________________________________________________________
Have You Applied For The Requested Assistance With A Government Agency?
..._¯Yes _¯No - If Yes List Result Or If No List Why Not:
___________________________________________________________________
Have You Applied For The Requested Assistance With A Charity Specific To Your Illness Or Specific To Your Need?
..._¯Yes _¯No - If Yes List Result Or If No List Why Not:
___________________________________________________________________
List Any Health Insurance:______________________________________________
Number Of Persons In Your Household: Age 18 & Over:_____ Under Age 18:_____
Number Of Persons In Your Household Who Are Employed:_____
Your Employer:________________________ Contact:_______________________
...Employer Phone Number:(____)____-______ Extension #:______
ASSETS:
Value Of House(s) Owned:$_________ Value Of Real Estate Owned:$_________
Checking Account Balance:$_________ Other Bank Account Balances:$________
Stocks & Bonds:$_________ Vehicles:$_________
List The Policy Value Death Benefit And Cash Value Of All Life Insurance Policies:
___________________________________________________________________
List All Other Assets:_________________________________________________
___________________________________________________________________
INCOME:
Your Total Gross Monthly Income Before Taxes: $_________
Your Net Monthly Income After Taxes:$_________
Social Security Income: $_________ Income From Dividends:$_________
List Other Income:___________________________________________________
Gross Monthly Income Of All Household Members Without Yours: $_________
Net Monthly Income Of All Household Members Without Yours: $_________
MONTHLY EXPENSES FOR ENTIRE HOUSEHOLD:
Rent:$_______ -OR- Mortgage:$_______
Electricity:$_______ Gas Utilities:$_______ Water:$_______ Phone:$_______
Transportation Expenses:$_______ -OR- Gasoline:$_______ + Car Pmt:$_______
Food:$_______ Clothing:$_______ Out Of Pocket Medical Expenses: $_______
Other Necessary Living Expenses (List Each Item With Monthly Amounts.):
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Any Other Information That You Would Like To Tell Us About:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
CHECK LIST FOR ATTACHMENTS REQUIRED:
_¯1) Letter from your physician within the past six (6) months stating that you have
.....a terminal illness or a life threatening severe chronic illness that is an ongoing
.....serious disability and what the illness is and what type of care you need.
_¯2) Copy of your social security card.
_¯3) Copy of your valid state or federal picture identification or the photo & name
.....page of your US Passport.
_¯4) Any back up that you may have for the assistance that you are requesting,
.....for example; lease & rent statement, utility bills, prescription costs, etc.
_¯5) Copies of your sources of income (payroll check stub, W-2, 1099, etc.
_¯6) Copies of requests and denials from other sources for the assistance that you
.....are requesting.
RELEASE:
I hereby give We Are Alive, Inc. permission to contact and discuss my case with anyone listed on this request, on the documents I provide, that I verbally provide or that is necessary to contact to process my request. I understand that if my request is approved, that We Are Alive, Inc. does not pay me directly, but pays my vendors or providers. I understand that We Are Alive, Inc.'s name and logo on their checks, stationary, forms, etc. as well as their check memo which will reference my name, social security number and type of assistance, will more than likely make it known to my vendors or providers that I have a terminal or severe chronic illness. I understand that We Are Alive, Inc. does what it can within reason to keep my medical information confidential outside the area of providing assistance to me, but that We Are Alive, Inc. can not guarantee that my information will remain confidential. By signing this document and requesting assistance I hereby release We Are Alive, Inc., its board members, its officers, its volunteers, its staff, its consultants and its members from any liability or claims whatsoever that I may have now or in the future. I certify that the information that I have provided to We Are Alive, Inc. is complete and correct. If I fax or email this form, I agree that my faxed or scanned signature is to be treated as my original signature.
Signature:X_________________________ Date:___/___/___ (month/date/year)
If the recipient above is not able to sign or is under the age of 18, the recipient's legal guardian must sign below, hereby confirming the statements made hereon and agreeing to the terms and conditions stated hereon.
Signature:X_________________________ Date:___/___/___ (month/date/year)
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