TJ Whalen Assistance Form Application TJ Whalen Patient Assistance Fund applications will be reviewed by RSDSA’s Assistance Program committee on a case-by-case basis. The grant is for non-emergency financial expenses only. It is a one‐time award. This grant is to offer assistance with accessibility support, assistance programs, medical, and other non-emergency assistance to the CRPS community. This application must be filled out in its entirety to be considered. Please allow sufficient time to be processed. Email questions to [email protected].Date *First and Last Name *Street Address *Apartment, suite, etcCityStateZIP / Postal CodePhone Number *Email Address *Do you have CRPS? *YesNoPlease provide medical documentation that you have CRPS. The document must be within one year of the date of this application.If you're unable to upload documents, please send the documents to [email protected] or mail them to RSDSA PO Box 502 Milford, CT 06460Choose FileNo file chosenDelete uploaded fileDo you currently have a doctor that is treating your CRPS? *YesNoAre you currently employed? *YesNoDoes your employer provide health insurance? *YesNoAre you currently living on your own or with a caregiver? *On My OwnWith a CaregiverIf you are living with a caregiver are they...? *Family MemberFriendPaid PositionOtherWho is paying for your caregiver? *0 / 50Are you applying for or currently receiving SSI?ApplyingReceivedHow much have you received? *0 / 20Are you applying for or currently receiving SSDI?Applying ForReceivedHow much have you received? *0 / 20If denied for SSI or SSDI, have you reapplied?YesNoWhen did you reapply? *0 / 20Please attach a copy of a letter from the Social Security Administration stating that you have applied or have been awarded benefits.If you're unable to upload documents, please send the documents to [email protected] or mail them to RSDSA PO Box 502 Milford, CT 06460Choose FileNo file chosenDelete uploaded fileAre you applying for or currently receiving SNAP?Applying ForReceivedHow much have you received? *0 / 20Are you applying for or currently receiving housing assistance?Applying ForReceivedHow much have you received? *0 / 20Are you applying for or currently receiving a grant for training or college?Applying ForReceivedHow much have you received? *0 / 20Are you applying for or currently receiving Medicare?Applying ForReceivedHow much have you received? *0 / 20Are you applying for or currently receiving Medicaid?Applying ForReceivedHow much have you received? *0 / 20Are you applying for or currently receiving Workers’ Comp?Applying ForReceivedHow much have you received? *0 / 20Are you applying for or currently receiving any other funds such as funds from a faith community or service club?Applying ForReceivedHow much have you received? *0 / 20What is the total net monthly income for your household? *0 / 20What are your total monthly medical expenses? *0 / 20Do you attend support groups and/or educate yourself on your CRPS? *YesNoIf yes, what group(s) do you attend/visit virtually? *0 / 20How did you find out about the TJ Whalen Assistance Fund? *0 / 100Why do you feel you should receive assistance from the TJ Whalen Assistance Fund? *0 / 100What are you requesting assistance for? Please summarize your request including costs. *If you’re applying for assistance to pay for accessibility improvements to your home, or for other assistance, please provide quotes/other relative information for the amount you are requesting. Previous expenses will not be considered.0 / 150Please list additional circumstances that you would like us to consider in determining your eligibility.0 / 150Please include the first page of your latest IRS 1040 or 1040EZ.If you're unable to upload documents, please send the documents to [email protected] or mail them to RSDSA PO Box 502 Milford, CT 06460Choose FileNo file chosenDelete uploaded fileUpload additional documents that you would like to share with RSDSA’s Assistance Program Committee.If you're unable to upload documents, please send the documents to [email protected] or mail them to RSDSA PO Box 502 Milford, CT 06460Choose FileNo file chosenDelete uploaded fileSubmit
