Full Name Address City/State/ZIP Phone Your email Preferred Contact PhoneEmailText Medical Insurance PrivateMedicareMedicaidOtherNoneMarital/Household Status SingleMarriedDomestic PartnershipDivorcedWidowedOtherNumber of people living in your household Number of dependent children in household Type of Limb Loss LowerUpperMultipleOtherDate of Amputation/Limb Loss Prosthetic Provider Date of amputation, if applicable Primary cause of amputation or limb loss Trauma or InjuryDiabetes or Vascular DiseaseCancerInfectionCongenitalMilitary ServiceOtherEmployment Status Full timePart timeRetiredSSDI/DisabilityNoneAssistance Requested related to your amputation (check all that apply) Prosthetic-related expensesProsthetic supplies or repairsMedical expensesTransportation assistanceAdaptive equipmentHome accessibility needsRehabilitation supportEmergency assistanceOtherAmount Requested Explain your request Financial Hardship Statement: (What happened that required this request) Have you applied for assistance from another organization, government program,insurance company, or charitable fund for this same need? YesNoUnsureIf yes, please list Organization, Amount Requested, and Amount Received Supporting Documents Applicant Agreement: I certify the information is accurate. I understand assistance depends on available funds and committee approval. Clear
