TETWP Application – Florida Gateway Fairgrounds formerly Columbia County Fairgrounds

PATIENT AND SPOUSE DOCUMENTS TO BE PROVIDED
If your application for assistance is considered favorably, copies of the following documents may be requested. Are you willing to provide these? If No, please explain.
Last Federal Income Tax Return (Yes/No):*
If No, Why?
Proof of Public Assistance (Yes/No):*
If No, Why?
Bank Statements (last 90 days) (Yes/No):*
If No, Why?
Statements of Other Income (Yes/No):*
If No, Why?
Please provide the following information that you have available to Florida Gateway Pink Crisis Fund:
Identification
- Florida Driver's License / FL identification Card
Or 2 of the following:
- Birth Certificate
- Voter's Registration Card
- Alien registration Card
- Affidavit of Identification (notarized)
Please provide all that apply (if applicable):
- Most recent tax return, 1040 (including supporting schedules) and W2's for all wages
- Pay Stubs for previous 4 pay stubs
- Bank statement (previous 3 months for all accounts)(include all pages)
- Social security benefits for any family members
I will send the above documents to Florida Gateway Pink Crisis Fund by:*
- Mailing the documents to the Florida Gateway Pink Crisis Fund office at the fairgrounds.
  164 SW Mary Ethel Lane, Lake City, FL 32025
- Drop the documents off at the Florida Gateway Pink Crisis Fund office at the fairgrounds.

Please answer the following questions.
Please write your answers in the text boxes for each question.
What is the amount of assistance you are requesting?
Please enter a number from 0.00 to 3000.00.
The maximum you can apply for is $3,000.
How did you hear about our Charity Program?
What other sources of assistance have you applied for?
What other means have you exhausted in trying to raise money?
Have you received any additional funds from these resources?
Do you have insurance? If so, what kind?
How has this medical condition affected your life? What adjustments are you having to make?
What is your treatment plan? Send us a letter from your doctor if you have one.
Please provide any additional information that you think the Association needs to know to consider your request.
Please provide a specific list of all other charity care for which you have applied.
Please describe your personal situation and reasons for requesting assistance.

Acknowledgment
This is to advise that I have pursued all other avenues possible for payment, including private insurance, governmental and charitable agencies providing funding and relief from financial obligations: therefore, I hereby request Florida Gateway Pink Crisis Fund make a determination of my eligibility for their Charity Care Program. I understand that the information I submit concerning my income, family size, assets, expenses and medical bills is subject to verification by Florida Gateway Pink Crisis Fund. I also understand that if the information I submit is now or at any time in the future determined to be false, such determination will result in current and/or retroactive denial of Charity Care and I will be liable for charges for services rendered. I certify that all of the information in this form is true and correct. Incomplete and fraudulent applications will be denied. I acknowledge that by submitting this completed application for consideration, I can withdraw said application at any time and the Tough Enough to Wear Pink is in no way obligated to distribute any funds for my benefit

I understand that if I am approved through this program, I must submit medical invoices to Florida Gateway Pink Crisis Fund for processing.
With my electronic signature immediately below, I certify that ALL the information above is understood and correct:*
A copy of this application will be emailed to you at the email address you provided above.

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