1. Applicant** Information: Name * Address * City: * State * Zip * Phone 1 * Email * Phone 2 Who referred you to BDFNC? * May we contact this person? Phone Number Where do you receive treatment for your bleeding disorder? * List contact information for above: * Have you spoken with a social worker about potential resources? * If yes, who and when? List contact information for that person : 3. Request for Assistance: Amount requested * Reason for this request * 4. BDFNC requires applicants first seek assistance from two agencies before applying to BDFNC.
Please identify these agencies below: Name * Phone * Status * Name * Phone * Status * **Parents of adult children with a bleeding disorder or spouses of a person with a bleeding disorder
may NOT apply on behalf of their spouse or adult child unless they provide an explanation of disability
that prevents the adult with a bleeding disorder from applying on their own behalf. 5. Creditor - the business/individual to whom BDFNC should send the check: Name * Address * City * State * Zip * Phone * Account Number 6. Please list ALL members of the household (including non-family members). 6. Please list ALL members of the household (including non-family members).
* Types of relationships can include: self, spouse, parent, sibling, roommate, etc.
7. Employment Information: Applicant’s Employer * Address City State Zip List of employers of other household members * TOTAL Monthly Household Income * (List ALL income from ALL other members of the household. Sources of income can include:
employment wages, unemployment, SSI/SSDI/SSD, Food Stamps, spousal/child support, assistance
from relatives, etc. BDFNC reserves the right to request a copy of your most recent tax return for
verification of income.) Have you applied for assistance from HNC or BDFNC in the past? * If yes, please give month/year: PLEASE NOTE: Bleeding Disorders Foundation of North Carolina (BDFNC) grants are never made directly to individuals, only to creditors that can be verified by BDFNC. Because of its limited resources:
BDFNC does not make grants in excess of $500 per calendar year.
BDFNC assistance is limited to two consecutive years. After two years, applicants must wait one year before applying again for assistance.
BDFNC reserves the right to take into consideration whether an applicant has been a "no show" as defined in its
Events Registration and Attendance Policy Personal Information will not be used or disclosed for purposes other than those for which it was collected. At no time is personal information shared with any individual, company, or organization
outside of BDFNC.**
Submittal of Bill: All pages of the bill in question must be submitted to BDFNC before the application for financial assistance can be reviewed. Please check the option below that applies: Please Explain: ** BDFNC maintains its own private database of contact information that is used to send out information relevant to people with bleeding disorders, including events around the state. If you wish to be
removed from the database, please call BDFNC at (919) 319-0014. Type Signature of Person Completing the Application *