National Gaucher CARE Foundation, Inc.

2020 CARE and CARE+PLUS Program Application

Patient Information

Are you a returning applicant or a new applicant?

Returning ApplicantNew Applicant

Please enter your Patient ID here (If you do not have your Patient ID, please enter your email or your legal guardian's email here. ALL applicants are required to have an email.)

Patient First Name

Patient Last Name

Patient Date of Birth (mm/dd/yyyy)

Address Line 1

City

Country

State

Postal Code

Federal Poverty Level % (Please ensure you calculated based on last year's annual income, the AGI - line 7 on your 1040).

Applicants whose Federal Poverty Level is above 400%, do not meet the eligibility criteria. Thank you for your interest in the CARE Programs.

Occupation

Gender

Marital Status

Gender - Self Describe

Patient Phone Number

Patient Email

Preferred Number

Home

Work

Cell

Legal Guardian's Phone Number

Legal Guardian Email

Preferred Number

Home

Work

Cell

What therapy drug do you currently use?

Thank you for your interest in CARE. These programs are available SOLELY for US Citizens residing in the continental US. Please contact the International Gaucher Alliance, https://gaucheralliance.org/

Financially Responsible Party #1 (FRP1)

Who is the Financially Responsible Party?

First Name

Last Name

Date of Birth (dd/mm/yyyy)

Email

Same address as patient?

YesNo

Address Line 1

City

Country

State

Postal Code

Occupation

Gender

Marital Status

Gender - Self Describe

Phone Number

Preferred Number

Home

Work

Cell

Number of Dependents (Please include self)

Financially Responsible Party #2 (FRP2) (2-income family only)

Who is the Financially Responsible Party?

First Name

Last Name

Date of Birth (dd/mm/yyyy)

Email

Same address as Patient?

YesNo

Address Line 1

City

Country

State

Postal Code

Occupation

Gender

Marital Status

Gender - Self Describe

Phone Number

Preferred Number

Home

Work

Cell

Page 2

All fields are required. Please enter 0 if there is no applicable amount.

Gross Monthly Family Income

Combined Salaries

$

Social Security Disability

$

Social Security Retirement

$

Private / Job-Related Disability

$

Pensions

$

Alimony / Child Support

$

Unemployment

$

Other Income

$

Total MONTHLY Income (Raw)

$

Total MONTHLY Income

$

If no income, please explain why: (eg. student, unemployed, etc.) or type N/A for not applicable

Supplemental Information

Assets

Adjusted Gross Income 2018

$

line 7 on 2018 1040 or 8b on 2019 1040 income tax return OR, if receiving Social Security, benefit amount. If the Adjusted Gross Income is 0, please enter 0.

Marketable Securities

$

Restricted Securities

$

Monthly Liabilities

Mortgage / Rent

$

Credit Cards

Visa

$

Discover

$

MasterCard

$

American Express

$

Other Cards

$

Car Loans

$

Car Insurance

$

Homeowners / Renters Insurance

$

Signature Loans

1

$

2

$

Food

$

Utilities

Electric

$

Gas/Oil (for heating)

$

Water

$

Phone (Landline)

$

Phone (Cell)

$

Internet

$

Gasoline, Bus/Train/Cab Fare

$

Do you have other MONTHLY expenses?

Other Monthly Expenses (Please indicate the type of expenses in the Comment section in the next page)

1

$

2

$

3

$

4

$

5

$

6

$

Total MONTHLY Liabilities (Raw)

$

Total MONTHLY Liabilities

$

Page 4

General Verification Documents

IMPORTANT! This application can not be considered without the Foundation receiving, either electronically or by mail, all of the following required documents:

- 2019 Income tax return, or 2018 if 2019 hasn't been filed, or 2019 Social Security statement if no taxes filed

- Proof of Insurance (see requirement details below for those applying for a CARE grant)

- Waiver & Release of Liability - Download Form

- Medical Statement of Need (Only required for NEW Applicants) - Download Form

- Applicants whose Federal Poverty Level is between 300% - 400%, are required to provide verifying documentation to demonstrate extraordinary financial hardship beyond income.

Please upload only PDF documents

Do you plan on sending documents via mail, ie US Post? AS OF MARCH 19, 2020 NO DOCUMENTS CAN BE ACCEPTED VIA MAIL. PLEASE UPLOAD ALL DOCUMENTS TO THIS APPLICATION. IF YOU ARE HAVING DIFFICULTY, EMAIL CARE@gaucherdisease.org or call 301-900-1053.

YesNo

Mail Details

If you would like to mail your documents, please send to:

NGCF
5410 Edison Lane, Suite 220
Rockville, MD 20852

NOTE: Your application is not complete and will not be submitted for consideration until all required documentation is received. Please ensure you 'SAVE' this application by clicking on the link at the bottom of the page. The NGCF will notify you once your documentation is received and attached to the application. Once notified, you will need to return to your application to review, certify and submit it.

Please read carefully as applications without the proper Proof of Insurance (POI) attached will not be considered.

It is the applicants responsibility to provide the appropriate required documentation. NGCF will not contact applicants to request proper documentation.

If you have questions, please email, care@gaucherdisease.org, or call, 301-900-1053, prior to submitting your application.

Proof of Insurance is:

IF APPLYING FOR THE UPCOMING CALENDAR YEAR (i.e. in autumn of current calendar

year):

FOR PRIVATELY PAID INSURANCE PLANS:

A copy of your notification from your insurance carrier(s) regarding your 2020 insurance premium cost AND policy calendar year, i.e. January 1 - December 31 OR July 1 - June 30, etc.

IF APPLYING FOR EMPLOYER SPONSORED PLANS:

A copy of your most current pay stub indicating the cost of your insurance deductions

AND

A verifying document from HR, such as a benefit table with your selected levels highlighted, as to your monthly group premium rates AND an indication of the policy calendar year dates, i.e. June 1 - May 31.

OR

IF APPLYING AFTER JANUARY 1 FOR THE CURRENT CALENDAR YEAR:

FOR PRIVATELY PAID INSURANCE PLANS:

A copy of your most current invoice from your insurance carrier(s) indicating your insurance premium cost AND policy calendar year, i.e. January 1 - December 31. This can be submitted as two separate documents if needed.

FOR EMPLOYER SPONSORED PLANS:

A copy of your most current pay stub indicating the cost of your insurance

AND

A verifying document from HR, such as a benefit table with your selected levels highlighted, as to your monthly group premium rates as well as the policy calendar year dates, i.e. June 1 - May 31.

YOUR INSURANCE POLICY CALENDAR YEAR IS REQUIRED AS PART OF THE VERIFYING DOCUMENTATION

If you are completing the application prior to January 1 for the upcoming calendar year, it is your responsibility to ensure the proof of insurance you are providing accurately reflects the 2020 premium for each policy.

If your policy effective year is not January 1 - December 31, you must also provide documentation that verifies the policy calendar year, i.e. the letter last received by the health insurance carrier informing you of your premium rate as well as the effective date of the premium change.

Tax Return 2018 or 2019 Social Security Statement

Waiver & Release of Liability

Medical Statement of Need (only required for NEW applicants)

If you are applying for CARE Insurance Premium Assistance, Proof of Insurance is required

Applicants whose Federal Poverty Level is between 300% - 400%, are required to provide verifying documentation to demonstrate extraordinary financial hardship beyond income.

Comments

You may use this space to provide any additional information you feel we should know in order to process your application. Applicants whose FPL is between 300%-400%, are required to provide information as to the extraordinary financial hardship beyond your income for consideration of grant request:

Certification

I certify that the information contained in this application is complete and accurate to the best of my knowledge, and I agree to notify the NGF / NGCF of any changes as soon as I become aware of them. I understand that a failure to report changes in finances, which may affect grant eligibility, insurance policies and/or premiums as well as a timely audit completion may result in forfeiture of the remaining grant as well as repayment of funds. (Check box below)

Name

Date

All information provided by an applicant will be held in the strictest confidence and is the sole property of the NGF/NGCF, its staff and its advisory board. No information provided to the NGF/NGCF will be released to any other organization or entity unless the applicant signs an appropriate release of information.

Please keep copies of all correspondence sent to the NGF/NGCF including the application, financial statements and any other documents provided to the NGF/NGCF.

Grants requests are only considered for complete applications (see above requirements re: verifying documentation). The CARE grant calendar cycle is December - November as monthly CARE grants are disbursed the month prior, i.e. January grant checks are disbursed in December. Approved grant requests after mid-December in any calendar year, will commence with the CARE grant disbursement the following month and, therefore, will not be a full 12 month grant cycle.

Please note that it is possible for grant requests made by qualified applicants to be denied due to request exceeding available funds. This application in no way guarantees the receipt of or entitles the applicants to requested grant funds.

Page 2

Page 3

Page 4