NCF WBC Boxer's Charitable Fund Application (00050062)

WBC BOXERS’ CHARITABLE FUND REQUEST FOR ASSISTANCE

I. PERSONAL INFORMATION

Last name:______First name:______Mid. initial: ______

E-mail address (if available):______

Home street address: ______

City:______State:______Zip: ______

Work phone:______Home phone:______Cell phone: ______

II. REQUEST AND NATURE OF NEED INFORMATION

A. Requested amount: $ ($10,000 maximum request per year except under special circumstances)

Please thoroughly enumerate assistance requested and provide actual figures that can be verified by your back up documentation.

Company / Vendor Amount

Total Amount Requested

B. Description of crisis (please be specific): Financial hardship due to medical costs not covered by insurance or the cost of medical insurance (please describe):

C. Type of assistance requested (Please attach any valid supporting documents. Examples listed below may include, but are not limited to, the following.)

1 NOTE: For your request to be reviewed, you must provide the following documentation alon g with your completed application. Failure to provide supporting documentation may result i n the denial of your request. Please remember that assistance is provided based on a qualif ying event/crisis. Assistance is not provided solely on the basis of need.

*It is the responsibility of the applicant to provide copies of supporting documentation and black out all Social Security Numbers and bank account numbers.

All requests should include: ______Copy of applicant’s driver's license or any government issued ID ______Copy of the applicant’s most recent paycheck stub ______Recent bank statement (if available) ______Proof of income for spouse or domestic partner (if applicable)

Mortgage or rent payment Copy of rental/lease agreement or copy of mortgage coupon/statement bearing applicant’s name Copy of Pay or Quit notice or Eviction notice bearing applicant’s name Letter or statement from mortgage company indicating amount past due; eviction or foreclosure notices are also acceptable IRS Form W-9 from apartment complex or mortgage company.

Utilities (for example: water, gas, electricity, and waste disposal) Copy of utility bill bearing applicant’s name Copy of utility bill delinquency/disconnection/termination notice bearing applicant’s name or a statement from the utility company

Medical Illness or Injury ______Letter from physician explaining medical issue ______Proof of medical leave of absence ______Medical bill’s in applicant’s name ______Explanation of benefits issued by insurance company (if applicable) ______Copy of medical insurance bill

Other (please describe):

D. Have you attempted to make payment arrangements, if applicable (for example, utilities, rent/mortgage, etc.)?

No, I have not.

Yes, I have, but the company(ies) will not work with me.

2 III. PERSONAL FINANCIAL INFORMATION The following questions focus on your household income and expenses. The questions are not meant to be intrusive, but are a necessary step to provide information for the committee and ensure we a re following the rules of the IRS.

Income & Revenue A. Gross (before taxes) Annual Income: $ ______Net (after taxes) Monthly Income: $ ______Cash on hand: $ ______Savings Account: $ ______Checking Account: $ ______Do you receive any other form of income (i.e., child support, alimony, settlement, etc.)?

Yes, the form of income is:______; I receive $______per month

B. Are you receiving any Worker’s Compensation or Union Compensation?

Yes, the form of income is:______; I receive $______per week/month (circle one)

IV. HOUSEHOLD COMPOSITION

A. How many people live in your household? ______

B. Are there minor children, who you are financially responsible for, that live in your household?

Yes ______(number of minor children)

C. Do you live with a spouse/domestic partner? No

Yes, my spouse/domestic partner’s net (after taxes) monthly income is $______.

D. Do you own or rent your residence? Own

3 By signing below, under penalty of perjury, I declare, to the best of my knowledge and belief, the above stated information is true and correct. I authorize NEVADA COMMUNITY FOUNDATION to disclose any confidential and/or financial information to the third-party administrator as it pertain s to the above request. I voluntarily authorize the release of my protected health information to the administrator for processing of this application.

I understand the criteria, eligibility and application process of the WBC BOXERS’ CHARITABLE FUND.

Signature of applicant: Date:

Please transmit the application form and any supporting documentation to ONE of the following addresses to the attention of Jane Ramos, Director of Operations:

1. Via E-Mail: [email protected] or [email protected]

2. Via Mail or Courier (FedEx, UPS, DHL, etc.): Nevada Community Foundation 1635 Village Center Circle, ste. 160 Las Vegas, NV 89134, USA

3. Via Fax: (702) 892-8580