Request For Support Form

The Harbor Foundation Board of Directors (BOD) requires the completion of this form for submission and approval of a grant request. Verbal communication with any member(s) of the BOD or their representatives shall not substitute for submission of this form. Each space must be complete.

The Harbor Foundation Mission Statement

Harbor Foundation, Inc. is a 501(c)(3) charitable organization dedicated to improving the quality of life to assist persons in hospice care and their families with essential/extraordinary needs beyond what healthcare would normally provide, assisting bereaved family members, providing education about hospice, and such other charitable acts as may be approved by the Board of Directors. These expenses are those that the persons/families are unable to aﬀord themselves. Funds will not be allocated for patients’ needs which should be met by the hospice under the reimbursement system of Medicare, Medicaid, or any third-party payor.

Funds are made possible by the generosity of individuals, corporate donations, grants and endowments. The purpose is to enrich the lives of these patients and their families by relieving distress/hardship.

Applicant Information

Please check one

Check here if you have authorization to release patient information (HIPAA requirement)

Site administrator is aware and has been notified of request.

Patient Name *

Name of Social Worker or Representative *

Title *

Agency Name

City *

State/Province *

Agency administrator Name *

If approved, payment should be made to the following vendor *

Vendor Physical Address *

Vendor City *

Vendor State/Province *

Vendor Zip Code *

Vendor Phone Number *

Vendor Email *

Social Worker/Agency Representative

The Harbor Foundation Board of Directors (BOD) requires the completion of this form for submission and approval of a grant request. Verbal communication with any member(s) of the BOD or their representatives shall not substitute for submission of this form. Each space must be complete.

Patient Name *

Date of Birth *

Last 4 of SSN

Street Address

City *

State *

Phone Number *

Marital Status *

Number of Dependents *

Ages *

Monthly Income *

Description of Request

Request may not exceed $500.00. Patients may only receive assistance once from foundation. Any request exceeding the amount of $500.00 or assisting a patient/family more than one time must be approved by the Harbor Foundation board of directors.

* If requesting utility or any payments for which there is an account and account number, please attach documentation indicating the account holder’s name and account number. In some circumstances, the account holder’s SSN may be requested by the Harbor Foundation in order to apply the grant payment to the proper account.

Amount requested? *

Is this request urgent? *

Yes

No

Please oﬀer a thorough explanation of the patient and/or family circumstances that are causing ﬁnancial need.

Has the patient passed away?

Yes

No

If yes, Date of Death

If Requesting Final Arrangements, Cost (Cremation)

If Requesting, please list Funeral Home Handling Arrangements

Explanation of Arrangements:

Have you ever requested/received funding from Harbor Foundation?

Yes

No

Explanation of previous request or funds received:

Procedure for Completed Application

All completed Request for Foundation Support are subject to limits established by the Foundation guidelines. Requests will be sent to The Harbor Foundation Executive Board for review. A representative of the Foundation will contact you within 72 hours of receipt. If request for funds is urgent, an answer will be sent within 24 hours of receipt. The Foundation, as a non-proﬁt entity, may require a follow-up report to verify the donation was spent in accordance with this request. Please designate the individual(s) responsible for submitting a follow-up report and supplying the requested information.

Submitter's Name *

Date * +

Submitter Phone # *

Submitter Email *

Upload Documents

Please attach any supporting documents. (Examples: bill for payment request, quote from a vendor for service, denial letters from attempts of other agencies financial request.)