Application For Assistance

Please complete this application and submit with written documentation of diagnosis.

Tricia’s Hope INC does not discriminate and awards grants to individuals in need based on available funds.

Name*
First Last
Address*
Street Address City State ZIP Code
Phone*
Email*
Diagnosis*
I will provide written documentation of diagnosis by:*
- Upload
- Mail
Written documentation of diagnosis is required; applications are considered incomplete until documentation has been received. You can upload or mail documentation.
Tricia's Hope
4209 SR 43 N
West Lafayette, IN 47906
Upload Documentation of Diagnosis*
Drop files here or
You can submit multiple files; files upload directly and securely to our DropBox account.
Current Cancer Treatment Plan*
Number of Individuals Residing in Your Household*
Please enter a number from 0 to 15.
Annual Household Income*
Household Debt*
Monthly Expenses*
Please be as detailed as possible; all answers will remain confidential.
In what areas do you need help?*
- Emotional Support
- Spiritual Support
- Financial Support
What would you use financial assistance for at this time?*
Signature*