Natural Disaster Financial Assistance Program Application Form

1. Applicant Information**:

Name *

Address *

City: *

State *

Zip *

Phone 1 *

Email *

Phone 2

2. Referral Information:

Who referred you to BDFNC? *

Where do you receive treatment for your bleeding disorder? *

3. Request for Assistance:

Amount requested *

Maximum assistance at this time is $500 per household.

What is your most urgent need that we can help with? Check all that apply. Please understand that as an organization, we cannot provide cash or cash equivalent items (example: Visa giftcards) *

Grocery gift card (can include Walmart, Target, Food Lion, etc.)
Repair costs for damages (can include giftcards to hardware store)
Rent/Utility assistance
Temporary housing
Other (please describe bill or other item you need assistance with in notes below)

What grocery stores are near you? Please list a few (if possible) as we are trying to find ones that provide electronic giftcards.

If you selected "Other", please tell us what we can help pay. Please understand that as an organization, we cannot provide cash or cash equivalent items (example: Visa giftcards)

How has the natural disaster impacted you? Damages to house, out of work, etc. *

4. Please list ALL members of the household starting with yourself (including non-family members).

Name

Age

Does this person have a bleeding disorder?

Yes
No

Type of bleeding disorder

Relationship to person with bleeding disorder *

* Types of relationships can include: self, spouse, parent, sibling, roommate, etc.

Submittal of Bill (if applicable): 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:

I am attaching complete documentation of the bill to this application.
I need to send complete documentation of the bill separately.

Please Explain:

File Upload

Click or drag a file to this area to upload.

** 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 *

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1. Applicant Information**:

2. Referral Information:

3. Request for Assistance:

4. Please list ALL members of the household starting with yourself (including non-family members).