Application for Financial Assistance Please enable JavaScript in your browser to complete this form.PERSONAL INFORMATION - Step 1 of 5Name *FirstLastLayoutPhone Number *Date of Birth *Layout (copy)Email Address *EmailConfirm EmailMarital Status *Taxpayer Registration NumberHome Address *Mailing Address *Layout (copy) (copy)Monthly Rent or House Payment *Length of Time at this address *NextHousehold Member 1 Name *FirstLastLayoutAge *School AttendingLayoutEmployerMonthly IncomeCommentsHousehold Member 2 Name FirstLastLayout Age School Attending LayoutEmployer Monthly Income CommentsHousehold Member 3 NameFirstLastLayoutAgeSchool Attending LayoutEmployerMonthly IncomeCommentsHousehold Member 4 NameFirstLastLayoutAgeSchool AttendingLayoutEmployerMonthly IncomeCommentsHousehold Member 5 NameFirstLastLayoutAgeSchool AttendingLayoutEmployerMonthly IncomeCommentsAttach additional sheet if more fileds are required Click or drag a file to this area to upload. PreviousNextLayoutName of Employer *Monthly Income *LayoutEmployer Phone Number *Length of Employment *Employer Address *PreviousNextProof of EmploymentEmployees 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 DocumentationA 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.PreviousNextUpdating preview…This is a preview of your submission. It has not been submitted yet! Please take a moment to verify your information. You can also go back to make changes.PreviousSubmit
