Seeking Financial Assistance - Adassa Martin Foundation

Application for Financial Assistance

PERSONAL INFORMATION - Step 1 of 5

Name *

First

Last

Phone Number *

Date of Birth *

Email Address *

Confirm Email

Marital Status *

Taxpayer Registration Number

Home Address *

Mailing Address *

Monthly Rent or House Payment *

Length of Time at this address *

Household Member 1

Name *

First

Last

Age *

School Attending

Employer

Monthly Income

Comments

Household Member 2

Name

First

Last

Age

School Attending

Employer

Monthly Income

Comments

Household Member 3

Name

First

Last

Age

School Attending

Employer

Monthly Income

Comments

Household Member 4

Name

First

Last

Age

School Attending

Employer

Monthly Income

Comments

Household Member 5

Name

First

Last

Age

School Attending

Employer

Monthly Income

Comments

Attach additional sheet if more fileds are required

Click or drag a file to this area to upload.

Name of Employer *

Monthly Income *

Employer Phone Number *

Length of Employment *

Employer Address *

Proof of Employment

Employees submit copies of 3 months of paystubs

Click or drag a file to this area to upload.

Self-employed individuals submit a letter stating your business and monthly revenue - this must be notarized by a justice of the peace, a pastor, or a school principal

Click or drag a file to this area to upload.

Unemployed individuals submit a letter stating as such - this must be notarized by a justice of the peace, a pastor, or a school principal

Click or drag a file to this area to upload.

Retired individuals submit copies of 3 months of pension payments, if applicable.

Click or drag a file to this area to upload.

Medical Expense Documentation

A copy of the invoice for which payment is requested must be stamped and dated by the medical provider and submitted with this application with the date of service indicated

Click or drag a file to this area to upload.

Requirements for Financial Assistance Consideration

This application and all necessary documentation must be received by the Adassa Martin Foundation within 30 days from the date of invoice.

Our volunteers diligently process applications as soon as possible. Average response time is 2 weeks or less. If financial assistance is approved, all payments will be made directly to the medical service provider.

Funding is contingent upon available resources and financial qualifications. Your patience is appreciated while we work to ensure access to medical care for the people of Jamaica.

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Application for Financial Assistance

Household Member 1

Household Member 2

Household Member 3

Household Member 4

Household Member 5

Proof of Employment

Medical Expense Documentation

Requirements for Financial Assistance Consideration

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