REQUEST FOR AID

Please complete this aid request application for you or your loved one. Upon completion, the application will be emailed to the Foundation for review.

Who are you requesting aid for?

Yourself

A loved one

Name of recipient

First Name

Last Name

Name of Applicant (Only if requesting for someone else)

First Name

Last Name

Recipient's Email

Applicant Email (Only if requesting for someone else)

Recipient's Phone Number

(###)

###

####

Address of Recipient

Maryland Residents Only

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Applicant's Phone Number

Only if applying for someone else.

(###)

###

####

Relationship To Recipient

Only if not applying for yourself.

With as much detail as possible, please tell us how you, or your loved one has suffered a traumatic and life changing event that has left them in need of financial assistance. Please tell us how our Foundation may be able to help.

Does the Recipient know about this?

Only if you are applying for someone else.

Yes

No