General Hardship Application - Frontline Healing Foundation

This completed application packet will be reviewed by a committee representing Frontline Healing Foundation’s best interests. If approved, the Frontline Healing Foundation will provide a hardship grant to fund a portion of your treatment. If your health insurance covers all or part of the treatment, unused Frontline Healing Foundation funding will go directly back to the Foundation to help treat another Warrior.

The more details, clearer, and concise the information you provide, the easier it will be for the Board to make a decision. Your request may be denied or approved in full or partial, based on the financials provided. Misinformation, incomplete or information that doesn’t make sense may cause denial or delay due to the Board having to ask for additional information.

By signing this document electronically below, you certify that all the information included in this document is correct and true.

Name *

First

Last

Best Email *

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Physical Address (if different than mailing address)

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Other Phone

Date of Birth (MM/DD/YYYY) *

Age *

PERSONAL INFORMATION

1. What are you requesting funding from the Foundation for? *

If Other, please list the service here:

1b. If you are requesting funding for a K9, will you also be funding for Sober Living and IOP? *

Yes
No

2. Write a Narrative for why you need funding. (this is your chance to advocate funding for yourself). Include the following information in your narrative:

a. A brief history of your addiction (1-2 paragraphs maximum).
b. What will treatment do for you.
c. What will you do moving forward.
d. What is your support system at home like.
e. If in sober living, tell us about the program you are working (meeting status, sponsor status, job/school/volunteer status).

Your Narrative *

3. Do you collect VA compensation? *

Yes
No

If yes, what is your percentage of disability?

4. What is your employment status? *

a. If employed, where do you work, and for how long?

b. If unemployed, where was your last place of employment? And how long did you work there?

5. Please list your total sources of income (including spouse/partner/disability/etc). TOTAL Monthly Household Income: $ *

6. Please list your total expense (including rent/mortgage, insurance, vehicle, utilities, phone, child support, etc). TOTAL Monthly Household Expenses: $ *

7. Please provide the total balance in your bank accounts (including checking, savings, other): *

a. How much of this is useable income? $ *

8. Please provide total balance in any 401k’s, TSP’s (Thrift Savings Plan), etc: $ *

9. Have you received funding from any Foundation before for addiction/PTSD treatment? *

Yes
No

If so, where?

10. Do you have family members who are able to financially support a portion of your request? *

Yes
No

If so, what amount are they willing to assist?

11. What amount are you able to contribute towards your healing? *

12. Hardship amount requested less your contribution: $ (if applying for a sober living extension and have received received SL funds from the Foundation previously, your contribution must increase to the best of your ability) *

Please attach the following with your application below (Failure to do so may result in denial or delayed response):

DD214 (if Veteran) or LEO/FF/Other 1st responder – provide proof of current or former status (If you do not have your DD214, please obtain a copy from here:https://milconnect.dmdc.osd.mil/milconnect/)

Upload proof here

Click or drag files to this area to upload. You can upload up to 20 files.

Please attach the following with your application below (Failure to do so may result in denial or delayed response):

Bank statements (Last 3 months required) *

Upload all files here (Bank Statements)

Click or drag files to this area to upload. You can upload up to 20 files.

Please attach the following with your application:

Narrative & any letters on your behalf (optional)

Upload all file here (Narrative or Letters on your behalf)

Click or drag files to this area to upload. You can upload up to 20 files.

By signing this electronincally, you acknowledge you are applying for a Frontline Healing Foundation Hardship. You will be notified by Frontline Healing Foundation if you have been approved. Please note that approvals are good for 14 calendar days. If the warrior has not admitted into the program after 14 days, the approved scholarship will be void and will be utilized for other warriors in need. Any incomplete information may result in additional questions. Payment will be made directly to facility with invoice.

Digital Signature *

Date / Time *

Date

Time

Printed Name *

Facility Name *

Facility Contact Name and Email Address *

Facility Contact Number *