APPLICATION FORM
REQUESTING FOR SUPPORT
Please complete entire application with your personal information. Thank you.

Guidelines:

All applications are reviewed with respect to availability. Attention is given to every aspect of your application. Due to our limited resources, all applicants are not guaranteed approval. Several factors are considered when making our decision including negotiation of fees, and availability. We base our program on financial need, assisting the uninsured and underinsured.

If we are not able to contact you within a 30 day period your case will be closed. Please contact us with any questions or concerns. We are here to help and give you support.
ALL INFORMATION PROVIDED IS KEPT CONFIDENTAL. INFORMATION RELEASED FOR MEDICAL PURPOSES AND TREATMENT ONLY.
Eligibility requirements:

• An application must be completed in full submitted to PEOPLE WHO MAKE A DIFFERENCE FOUNDATION, to be reviewed. Once the application is submitted in full it will be referred for placement.

• US Citizens, Residence and Non-Residence are eligible

• Must live in Central Florida location for 6 months or more and must anticipate staying in Central Florida

If under 18:

FINANCIAL SUPPORT PROGRAM ELIGIBILITY CHECKLIST:

Monthly Expenses:

Mortgage/Rent:
Telephone/cell:
Car Payment and insurance:
Electric bill:
Gas, transport:
Food:
Tuition/Student expenses:
Health Insurance:
Out of pocket health Expenses:
Other expenses:
TOTAL
List of other people living in household:
Applications will not be processed unless we receive this information. PWMD reserves that right to request copies of all monthly expenses. If a request for a copy of monthly expenses is made the applicant must provide copies of said expenses to receive our finance support with 30 days of request.
You will be notified when your application is reviewed. Please do not hesitate to contact us with any question or concerns. If you need help completing the application please inform our office (407) 739-0612. We are here to help.

Applicant requesting for support signature:

email
info@peoplewhomakeadifference.org
adress
8751 Commodity Cir, suite 11
Orlando, FL – 32819