Hardship Assistance Fund

The Sahana Sinha Memorial Fund


This fund was created to honor and remember the life of Sahana Sinha, who was diagnosed with Wolf-Hirschhorn Syndrome, by assisting 4p- families who are experiencing financial hardships through the generous donations of her parents, family and friends to continue contributing to the community through this memorial fund.

We are very hopeful that this fund will help many families in need, and that the fund will continue to grow.  To make a tax deductible donation to this fund, please mail a check to our address below or use our PayPal donation link and note in the memo area that it is for the “hardship assistance fund”.
 
4p- Support Group
c/o Amanda Lortz, Executive Director
1495 Forest Brooke Way, #262
Delaware, Ohio  43015
 
OR
 


 

 

For Guidelines and Application, click HERE.

If you are unable to print and/or email your application, you may use the form below to submit your application with a digital signature.  Please note, you are still required to review the Guidelines which can be found in the link above.

Your Full Name (required)

Your Email (required)

Your Address (required)

City (required)

State (required)

Zip (required)

Your primary phone Number (i.e. 888-888-8888) (required)

Your mobile phone Number (i.e. 888-888-8888) (required)

Individual with 4p-'s First and Last Name (required)

Individual with 4p-'s Date of Birth (i.e. MM/DD/YYYY) (required)

Please describe your financial hardship? (required)

Please describe the assistance requested. (required)

Please describe how this assistance will directly affect your child with 4p-. (required)

Have you explored other funding resources? (required)

Additional comments. (required)

Provide the following documents (copies are preferred). Not doing so will delay our review process:

-Completion of all personal information as request above.
-Birth Certificate or State ID of Applicant(s) and the individual with 4p-. If the request is for burial expenses, a copy of the death certificate.
-Proof of income. Examples of Proof of Income are: Tax Return (most current filling year), Proof of State Funding (SSI, SSA, etc.), Unemployment Check Stubs
-At least one other request from another resource for funding that was denied to applicant, if applicable.
-Insurance denial letter, if applicable.
-Doctor's letter of necessity, if applicable.
-If requesting an item(s), copies of at least 3 bids.

Authorization:
I have done everything possible to look into other funding options before applying for this assistance. I certify that the information provided in this assistance application is true and correct as of the date set forth below. I authorize Jackie Dalzell, the HAF Committee Chairperson, to release this information to the HAF Committee regarding the application. My (digital) signature acknowledges and permits the 4p- Support Group and its agents to verify all information. Any intentional misrepresentation of information contained in this application will result in forfeiting assistance funding allocation now and in the future.

I am accepting this as my digital signature.

I have read and understand the HAF Guidelines.

I understand I must provide the documentation as noted above and will send either by email or postal mail before my application can be reviewed by the HAF Committee.

Must be a parent or legal guardian of an individual with 4p-.

Must be a registered member of the 4p- Support Group. (If you are not a member you can register by going to http://4p-supportgroup.org/membership/request-membership/.)

Applicant will understand that no cash or check will be furnished directly to them.

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