Qualification Guidelines for The Pink Fund
Please read carefully: The following information will help determine if you meet our qualification guidelines.
We are not an emergency fund and cannot provide immediate assistance. All grant decisions are made on the 3rd Monday of each month. Incomplete applications will not be accepted.
This page will help you get organized and prepared to complete the full application. Download this list here, or start the process by completing this page.
- The Pink Fund Application
- Application for Financial Assistance
- Medical Information (2 pages)
- HIPAA Privacy Authorization Form
- Bills Requested for Funding
- Financial Disclosure Form
- Media Release and Waiver (optional)
- A signed and dated letter (on letterhead) verifying your current diagnosis and detailing your treatment plan from one of the following: Oncologist, Licensed Social Worker, Patient Advocate, Nurse Navigator
- You will need an email address for your Social Worker, Patient Advocate or Nurse Navigator on page 4 of application.
- A signed and dated letter from your current employer (on company letterhead), verifying your current employment or leave status.
- A copy of your driver’s license or State ID Please note: the address on your ID must match the address on your application form.
- The front page of your tax return from the previous year
- W-2s or 1099s from the same year of your tax return
- A copy of your last 2 paycheck stubs
- A complete copy of all your checking and savings account statements for the last 2 months for you and your spouse or partner.
- Copies of ALL bills you wish considered for payment. The bills must show your name, or the name of your spouse or partner, your current address, the account number, the current balance due, and the complete address to which payments are sent.
Please DO NOT send originals.
- Bills considered for payment:
- Car Insurance Premiums
- Car Loans
- Health Insurance Premiums
- Phone Bills
- Utility Bills
*IF YOU RENT, you must send a complete copy of your lease/rental agreement, including the name and address of the person or agency to which payments are made.
We must have a current email address at which to contact you. If you do not have an email address, our communications will be through U.S. Mail and will delay the processing of your application.