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Apply for assistance

Paper applications are available by request only. Please email to request to fill out a PDF file to email or send by postal mail.


  • Complete each section of the application

  • Ensure ALL supporting documents are submitted along with the application

  • Ensure diagnosis falls under listed illness

  • Email completed application to

  • Review process may take up 2 - 3 business days, once completed, you will receive an "Notice of Action" email

  • Please read the application carefully. Answer each question completely with printed or typed answers. Attach another sheet if you need more space to answer questions. Failure to answer each question and provide required verifications may delay processing of your application or result in a denied application.

  • All required documentation should be submitted within 30 days from the date a completed application (completed, signed, and dated) is received. Please note that applicants are only eligible to apply every 6 months.

Apply Here

Additional Information

Choose illness:
Choose illness:
Choose illness:
Upload File
Upload File
Upload File
Upload File
Additional Resources Needed

Assistance Requested

Assistance Requested: Please place the amount next to each type of assistance requested, if known.

Employment Information

A. Is applicant currently employed?

List Three Previous Employers

If unemployed, has applicant registered with the Career Center?
Was applicant in the military?

Statement by Applicant: I hereby affirm that the facts in this application are true, correct, and complete, and that I have not knowingly withheld any information. I understand the Administrator has the right to verify any information necessary to determine my eligibility and hereby give my consent.

Thanks for applying! We’ll get back to you soon.

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