Medical Information (Section B)

ARE YOU IN ACTIVE TREATMENT? (Note: You must be in active treatment for a minimum of 90 days to quality for financial assistance.)*

YesNo

Employer Information (Section C)

ARE YOU CURRENTLY EMPLOYED? * (IF NO, SKIP TO SECTION D)

YesNO

Health Care Provider (Section D)

Health Insurance Information (Section E)

PRIMARY HEALTH INSURANCE PROVIDER: *

ALTERNATIVE HEALTH INSURANCE PROVIDER:

FAMILY INCOME SOURCES (Check all that apoly)

Social Security (retirement)SalaryPensionUnemploymentPublic assistanceShort-term disabilitySSD (disability)SSlFamily/Friends provide support

Note: Acceptable proof of income must be provided with this application – either mailed or emailed – and includes either a copy of the first two pages of your signed
income tax return or copies of your most recent pay stub, unemployment check or other form of income. For dependent children, the responsible parent or
guardian’s income will need to be verified.

Other (Section G)

TELL US YOUR STORY *

Prior to approval PNK Cancer Treatment Foundation will verify all information and documentation submitted.

Please be aware that submission of a completed application is not a guarantee of receiving financial assistance from PNK Cancer Treatment Foundation. Funds are
limited and based on eligibility and availability.

Any financial assistance will go directly to the applicant’s health care provider (funds will not go to the applicant).

All information is strictly confidential and is for PNK Cancer Treatment Foundation use only.

Once you have completed the entire application, you may send it electronically by clicking on the Submit button below—please ensure you have attached
appropriate documentation of your income sources for verification purposes.

As an alternative, you can mail your application and documentation of your income sources, to PNK Cancer Treatment Foundation, P.O. Box 40756, Arlington,
Virginia 22204 or you can fax your application and documentation of your income sources to 1-855-631-0097.