Page 1 of 6

Applying to Ray of Hope for Financial Assistance

Ray of Hope provides two different types of financial grants, an unrestricted fund and a guaranteed assistance subsidy that is based on
the applicant’s household income. The eligibility criteria for these two financial grants is different. You can use this application to apply
to either the fund, the subsidy or to both if you are eligible for both. If you are eligible for both, you can apply to both at the same time
or apply at separate times. See the eligibility guidelines below if you are eligible to apply for assistance from one or both of our
financial grants.
Unrestricted Fund
The unrestricted fund provides grants of $500 ($1,000 for pediatric patients) directly to Colorado cancer patients who are in active
treatment and in dire financial circumstances. If you receive this award, the check will be made out in your name.

Do you meet the eligibility for the unrestricted fund?

• I am 18 years or older, or am the parent/guardian of a patient under 18
• I am a Colorado resident
• I have a cancer diagnosis
• I am currently receiving cancer treatment that includes chemotherapy, targeted therapy, immunotherapy, radiation or
surgery, or I have completed one of these treatments within the past month
• I have a dire financial circumstance (expenses must be greater than income to meet this eligibility requirement)
If you have answered YES to every question, you are eligible to apply for assistance from the unrestricted fund

Guaranteed Assistance Subsidy

(based on household income)
The guaranteed assistance subsidy helps cancer patients that qualify as a low-income family, earning 175% or less of the Federal
Poverty Level. Assistance is for expenses such as rent or mortgage, utilities, telephone, car payment, health insurance, and other basic
expenses. If you receive this assistance, the check will be made out in your name.

Do you meet the eligibility criteria for the guaranteed assistance subsidy?
• Same as unrestricted fund
 I am 18 years or older
 I am a Colorado resident
 I have a cancer diagnosis
 I am currently receiving cancer treatment that includes chemotherapy, targeted therapy, immunotherapy,
radiation or surgery, or I have completed one of these treatments within the past month
 I have less than $5,000 in liquid assets.
 I have a dire financial circumstance (expenses must be greater than income to meet this eligibility requirement)
• With the addition that the gross income for everyone in the household does not exceed the income guidelines below

Income Guidelines
# in Household Gross Monthly Income
1 $1,732
2 $2,336
3 $2,940
$3,544
5 $4,148
6 $4,752
Add $604 for each additional person

If you have answered YES to every question, you are eligible to apply for the guaranteed assistance subsidy
Contact Information:
1385 S. Colorado Blvd, Suite 714
Denver, CO 80222
grants@rayofhopecolorado.org
Phone: 720-300-2095
Fax: 303-499-9229
Award limit: Applicants may receive one award per fund per twelve-month period, and a maximum of two lifetime awards from each fund for a total of four
awards from the Ray of Hope Cancer Foundation.
PATIENT NAME: _ _ Page 2 of 6

MEDICAL VERIFICATION FORM: THIS PAGE MUST BE COMPLETED BY A REFERRING PROFESSIONAL

Do not use abbreviations or codes for diagnosis and treatment. Do not send medical records. Answer each question
completely. Print clearly and use dark ink.

Parent/Guardian name (if patient is under 18):

Cancer diagnosis: Stage (please note if N/A):
Describe current treatment (begin & end dates are required): Diagnosis Date:
 Surgery Type: Date of Surgery: Name of physician:

 Chemotherapy Begin date: Anticipated end date:

Chemotherapy Agent(s):
 Radiation Begin date: Anticipated end date:
 Hormone Begin date: Anticipated end date:
Patient insurance status:  None  Medicare  Medicaid  CICP  VA  Private  Other:
Has the patient applied to RMCA or Ray of Hope before?  YES  NO
If yes, which one and when?
Is patient currently able to work?  YES  NO If no, what date will patient return to work?

Patient financial needs:

 Rent Mortgage Hotel/other housing Utilities Food Transportation Medical Other

**For the application to be eligible, we must have the following contact information**
Name of referring professional (health care professional completing form):
Facility: Banner Health KP RMCC RRMC SCL Health UCHEALTH Other

Address:

City: State: ZIP:

Phone: ( ) E-mail:  
Do you have any reservations concerning this patient’s request for financial assistance? YES NO
Referring professional’s summary regarding patient and their household’s financial situation:
(This is required, please include as attachment as needed)

Must be signed by referring professional (case worker, patient navigator, social worker, nurse, physician)
My signature below affirms the diagnosis and treatment information as described on this page.

Signature: Date:

Ray of Hope Cancer Foundation Grant Application Revised January 2020

PATIENT NAME: _ _ Page 3 of 6

PERSONAL DATA —TO BE COMPLETED BY GRANT APPLICANT (or parent/guardian if patient is under 18)
Answer each question completely. Print clearly and use dark ink.
Parent/Guardian name
(if patient is under 18): Patient Date of Birth:
Mailing Address: Apt #:
City: State: ZIP: County:
Phone: Home ( ) Cell ( )
E-mail address:
I am: Single Partnered Domestic Partnership/Civil Union Married Separated Divorced Widowed
Gender Identification:  Man  Woman  Trans*  Non-binary  Other:
The questions in this section are optional, and your answers are confidential. This information is reported generally and anonymously, to
help policymakers and advocates better understand and address health disparities in underserved groups. Occasionally, additional funds
may be available for some under-served groups.
Sexual Orientation:  Bisexual  Gay/Lesbian  Heterosexual  Other

Ethnicity:  African American or Black  Asian or Pacific Islander  Hispanic Native American
 White (non-Hispanic)  Other _

Education:  Grade school  High school  Vocational school  College  Graduate Post-graduate

How, when, and where is it easiest to reach you if we have questions?

Preferred language:
If employed or disabled, who is/was your employer:
How long have you/did you work for this employer?
What kind of work do/did you do?
After you have recovered, can you return to work for this employer?
List the names of all people living in your home
Name Relationship Age Employment (of adults over 18)
Full time Part time Disabled Retired Unemployed

Applicant Name Self

Comments (Explain unemployed or other situation)

Ray of Hope Cancer Foundation Grant Application Revised January 2020

PATIENT NAME: _ _ Page 4 of 6

INCOME & ASSETS — TO BE COMPLETED BY GRANT APPLICANT

Tell us about your total household income this month. Please report gross earnings (before taxes or other deductions). You’ll be able to
report the amount you pay in taxes and deductions on the next worksheet.

Attach copies of income for your entire household (paystubs, social security letters, pension statements, etc.)

Gross Start Date End Date

Income this month Monthly (date you (date you
began receiving Stopped
Amount this income) receiving this
(before taxes) income)
1) Your gross monthly income from working $
2) Your spouse/partner’s gross monthly income from working $
3) Other household members’ gross monthly income $
4) Sick leave, workers’ compensation, or disability insurance income $
5) SSI $
6) SSDI $
7) VA benefits $
8) Retirement, pension, 401-K or IRA $
9) Child support $
10) Spousal support $
11) Public assistance $
12) Food stamps $
13) Other income (unemployment or other ongoing income)
$
Describe:
Total Gross Monthly Income $

Assets
1) Checking account balance: $ Bank Name:
2) Savings account balance: $ Bank Name:
Write yes or no. If yes, provide value, loan, and income. Value Loan Income
3) Do you own or are you buying a home? $ $ $
4) Do you own or are you buying a car? $ $ $
5) Do you own or are you buying another car? $ $ $
6) Do you own a business or any part of a business? * $ $ $
7) Do you have any investments, stocks or bonds? $ $ $
8) Do you have any rental properties? $ $ $
9) Do you own any other real estate properties? $ $ $
10) Do you own any annuities? $ $ $
11) Do you own “cash value” life insurance? $ $ $
12) Do you have any other assets? $ $ $
*Note: If you answer “yes” to question #6, please provide a current balance sheet for your business.

Ray of Hope Cancer Foundation Grant Application Revised January 2020

PATIENT NAME: _ _ Page 5 of 6

EXPENSES — TO BE COMPLETED BY GRANT APPLICANT

Please list all your household’s expenses for every single member of your household this month so that we have an accurate picture
of your financial situation.

Prioritize your expenses in the “Priority of Need” column with #1 being the most important expense. If you are applying to the
RMCA fund, this is how we’ll know which bills you’d like help with this month.

Attach copies of your first and second top priority bills

Expenses This Month

Expense Payment/Amount Total Balance Priority of Need

1) Rent or mortgage
$
2) HOA fees $
3) Property taxes (if not included with mortgage) $
4) Home/renters (if not included w/ mortgage) $
5) Utilities (electric, gas, water, trash service) $
6) Telephone (land/cell), TV, internet $
7) Monthly food expense*: $200/m x # in house = $
8) Car payment(s) $
9) Car insurance $
10)Gasoline and oil $
11)Transportation (bus pass, cab fare, or other) $
12) Health insurance premium(s) $
13) Medical costs after insurance $
14) Prescription costs after insurance $
15) Life Insurance premium(s) $
16) Childcare/child support $
17) Pet care $
18) Other non-medical bills, payments, or loans* $
19) Credit card payments $
20) Taxes and other payroll deductions $
21) Tuition $
Total Monthly Expenses $

*Describe expenses from line 18 here (you can also use this space to clarify anything you’d like about your expenses):

Ray of Hope Cancer Foundation Grant Application Revised January 2020

PATIENT NAME: _ _ Page 6 of 6

GRANT REQUEST APPLICATION —TO BE COMPLETED BY GRANT APPLICANT

 Unrestricted fund only  Guaranteed assistance subsidy only  Both the fund and subsidy
Have you applied to other agencies for assistance?  Yes  No
If yes, please list the agency and their response to your request for assistance. If no, why not?
(We encourage you to seek assistance from any & all agencies & resources. Assistance from other resources does not affect eligibility)

Summarize your current financial situation (this is required). Include as attachment as needed.

I certify that the information provided on this application is true and accurate to the best of my knowledge. I authorize Ray
of Hope Cancer Foundation to obtain from the individuals, businesses, organizations, agencies, or entities listed in this
application whatever information is necessary about my case that might be helpful for assessing my application.

I release Ray of Hope Cancer Foundation of all liabilities or claims arising out of the donation of money or services
provided to me or my family.

Applicant’s Signature: Date:

 By checking this box, I allow the Ray of Hope Cancer Foundation to use my story (minus identifying characteristics) to solicit
donations/funding to further help others undergoing cancer treatment.

APPLICATION CHECK LIST:

 My name is on every page of this application.
 I have verified that my income does not exceed the guidelines listed on the application cover page, if I am applying for
the guaranteed assistance subsidy.
 I have included all income and expense information for my entire household.
 I have totaled the amounts on the income and expense pages (pages 3 and 4).
 I have attached copies of household income (recent paystubs, social security letters, pension statements, etc.)
 I have attached copies of the most recent statements for my top 2 priority expenses (mortgage, utility, etc.). (Do not include
bills for medical expenses, life insurance, credit cards, or bills payable to family members.)
 I have attached a copy of my photo I.D.
 A health care professional that is knowledgeable about my diagnosis and treatment has completed and signed the medical
verification on page 1.
 I have signed this application.

Ray of Hope Cancer Foundation Grant Application Revised January 2020