<p>Thank you for contacting The Pinehurst Sanger Foundation for beneficiary assistance. The Pinehurst Sanger Foundation is a small, local charitable foundation that is recognized by the IRS as an approved 501(c)3 organization. The foundation’s mission statement is: To help offset the extraordinary medical expenses required to care for individuals in dire financial need. The foundation’s charter requires that all approved benefit payments be made directly to service providers. Please fill out the form below to the best of your ability so that the board of directors can review your application for assistance and determine if benefits are possible. The board could use information on the scope of the possible beneficiary’s problems, current and future financial liabilities, available insurance and financial resources and the family’s long term financial prognoses.</p><p>Beneficiary Name Date______</p><p>Phone Number E-Mail Address </p><p>Sponsor’s Name </p><p>Phone number E-Mail Address </p><p>Beneficiary Story__(Attachment OK) </p><p>Please answer the questions below for beneficiary consideration. Sensitivity is our goal when asking these questions, however this survey is an unfortunate necessity while qualifying potential beneficiaries. Does this beneficiary have:</p><p>Employed responsible party? Yes No </p><p>Health insurance? Yes No </p><p>Insurance benefits remaining? Yes No </p><p>Past Due medical bills? Yes No If yes, approximate amount Ongoing medical bills/co pays? Yes No If yes, monthly amount </p><p>Past due medicine bills? Yes No If yes, approximate amount </p><p>Ongoing medicine bills/co pays? Yes No If yes, monthly amount </p><p>Contacted other agencies for assistance? Yes No </p><p>Have other agencies providing benefits? Yes No If yes which agencies </p><p>Is bankruptcy immanent? Yes No </p><p>Minimum amount needed to avoid bankruptcy </p><p>Amount of benefit you are requesting from this foundation </p><p>To email this completed form to The Pinehurst Sanger Foundation go to “File” on the upper left menu bar then “save as” to your computer then email form to the email address below. US Mail? See address below.</p><p>Thank you,</p><p>Shelley Porak c/o The Pinehurst Sanger Foundation, Inc 6255 W Quincy Ave Denver, Co. 80235 303-726-8873 [email protected]</p>