Application Application

Demographics

Household/Other Details


Assets

Income

Expenses

 

Medical Statement

Social Worker Info

Social Worker's Explanation

The narrative MUST include the following pertinent information. Provide a complete and detailed explanation of the circumstances which require this application for assistance. Incomplete or unclear narratives will cause the application to be denied. Include patient's plan to handle future expenses

Location Details

Social Worker's Acknowledgment and Signature

I attest that the information in this application is complete and accurate to the best of my knowledge.

Applicant's Acknowledgment and Signature

I confirm that I am authorized to prepare and submit this Hawthorne Fund Application for Financial Assistance. I have reviewed the information listed within this application and attest that it is true and accurate. I have reviewed and do accept the guidelines of the Hawthorne Fund. I acknowledge that the National Kidney Foundation of Florida (NKFF) may wish to verify the information in this application and agree to provide NKFF with any financial statements, credit reports, tax returns or other documents it requests for its verification purposes. I hereby authorize NKFF to disclose my health care information provided in connection with this application to any NKFF volunteers or staff as may become involved in the processing and review of this application.