<p> WBC BOXERS’ CHARITABLE FUND REQUEST FOR ASSISTANCE</p><p>I. PERSONAL INFORMATION</p><p>Last name:______First name:______Mid. initial: ______</p><p>E-mail address (if available):______</p><p>Home street address: ______</p><p>City:______State:______Zip: ______</p><p>Work phone:______Home phone:______Cell phone: ______</p><p>II. REQUEST AND NATURE OF NEED INFORMATION</p><p>A. Requested amount: $ ($10,000 maximum request per year except under special circumstances)</p><p>Please thoroughly enumerate assistance requested and provide actual figures that can be verified by your back up documentation. </p><p>Company / Vendor Amount</p><p>Total Amount Requested</p><p>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): </p><p>C. Type of assistance requested (Please attach any valid supporting documents. Examples listed below may include, but are not limited to, the following.)</p><p>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.</p><p>*It is the responsibility of the applicant to provide copies of supporting documentation and black out all Social Security Numbers and bank account numbers.</p><p>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)</p><p>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.</p><p>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 </p><p>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 </p><p>Other (please describe): </p><p>D. Have you attempted to make payment arrangements, if applicable (for example, utilities, rent/mortgage, etc.)?</p><p>No, I have not.</p><p>Yes, I have, but the company(ies) will not work with me.</p><p>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.</p><p>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.)?</p><p>No</p><p>Yes, the form of income is:______; I receive $______per month</p><p>B. Are you receiving any Worker’s Compensation or Union Compensation? </p><p>No</p><p>Yes, the form of income is:______; I receive $______per week/month (circle one)</p><p>IV. HOUSEHOLD COMPOSITION</p><p>A. How many people live in your household? ______</p><p>B. Are there minor children, who you are financially responsible for, that live in your household?</p><p>No</p><p>Yes ______(number of minor children)</p><p>C. Do you live with a spouse/domestic partner? No</p><p>Yes, my spouse/domestic partner’s net (after taxes) monthly income is $______.</p><p>D. Do you own or rent your residence? Own</p><p>Rent</p><p>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.</p><p>I understand the criteria, eligibility and application process of the WBC BOXERS’ CHARITABLE FUND.</p><p>Signature of applicant: Date: </p><p>Please transmit the application form and any supporting documentation to ONE of the following addresses to the attention of Jane Ramos, Director of Operations:</p><p>1. Via E-Mail: [email protected] or [email protected]</p><p>2. Via Mail or Courier (FedEx, UPS, DHL, etc.): Nevada Community Foundation 1635 Village Center Circle, ste. 160 Las Vegas, NV 89134, USA</p><p>3. Via Fax: (702) 892-8580</p><p>4</p>