Step 1 of 5 20% The application below is for assistance with medical and/or dental expenses, but NOT braces. Requests for assistance with braces are submitted through our partner, Smiles Change Lives. Please click here to verify your eligibility for Braces Assistance. For all other medical and dental requests, please complete the application below. Eligibility AssessmentIs child a US Citizen?*YesNoIs child under age 21?*YesNoIn which county does the child reside?*Coffey County, KansasLyon County, KansasOsage County, KansasElsewhereHas child resided in the county continuously for a minimum of one year?*YesNoYour child is not eligible. Your child must be under age 21, must be a US Citizen and must currently reside in Coffey, Lyon, or Osage County Kansas and have done so continuously for no less than one year immediately prior to application. Return to Home PagePlease click Next to proceed to the application. Application for Medical AssistanceReferred by:Is this your first time applying?*YesNoIf yes, how did you hear about us?*With what type of help are you needing?* Medical Expenses Dental Expenses What medical treatment was received or needed?*Medical Provider (click the plus sign to list as many providers as needed):*Medical Provider NameDate of Medical Services: What dental treatment was received or needed?*Dental Provider (click the plus sign to list as many providers as needed):*Dental Provider NameDate of Dental Services: Child's Information for whom you are applying.Click the plus sign at the right of the line below to add additional children, if needed.*First NameMiddle NameLast NameAgeDate of BirthGenderLast 4 digits SSN Ages of children-hidden field used for signatureDoes Child have medical insurance?*YesNoIf yes, Insurance Name:*Does Child have dental insurance?*YesNoIf yes, Insurance Name:Number of years Child has resided in Coffey, Lyon or Osage County:* Parent/Legal Guardian Household Information:Parent/Legal Guardian Marital Status*MarriedDivorcedSeparatedWidowedSingle (never been married)Living togetherCustodial Parent Name* First Last Relationship to Child*SelfMotherFatherLegal GuardianCustodial Parent Address* Street Address City State ZIP Custodial Parent Employer*# of Years*Less than one yearOne year or moreHourly Wage*Hours per week*Pay Frequency*WeeklyBi-WeeklyMonthlySemi-MonthlyContact name for household information questions*Phone # between 8:30 AM to 5:00 PM*Email* Including the child for which you are applying, how many children live in your home? DO NOT include yourself and your spouse/partner in this total.*Spouse/Partner InformationSpouse/Partner Name* First Last Spouse/Partner Employer*# of Years*Less than one yearOne year or moreHourly Wage*Hours per week*Pay Frequency*WeeklyBi-WeeklyMonthlySemi-Monthly If you do not file taxes, what is your reason?If the Child for which you are applying is NOT listed as a dependent on your tax return, who claimed & why?If household income is expected to be less than previous year, provide specific explanation below:Additional IncomeIf you or anyone in your household currently receives any of the additional income below, enter monthly amount received and provide proof.Cash Assistance (if none, type $0.00):*Child Support (if none, type $0.00):*Death Benefits (if none, type $0.00):*Disability (if none, type $0.00):*Food Stamps (if none, type $0.00):*Military (if none, type $0.00):*Retirement (if none, type $0.00):*SSI (if none, type $0.00):*Unemployment (if none, type $0.00):*Do you own, are purchasing, or rent your home? (check all that apply) Own or purchasing a home Rent a home or apartment Rent a lot for a mobile/manufactured home None of the above If own or purchasing, what is appraised value of home & acreage?*Amount of acreage included (if any)Current payoff amount of mortgage*If renting, amount paid per month*First and Last Name of Individual or Company Name to whom rent is paid*If none of the above, please explain*Do you own or purchasing a vehicle or vehicles of any kind, including but not limited to, cars, trucks, SUVS, vans, RVs, motorcycles or watercraft?YesNoItemize below ALL vehicles (even if amount owed is $0.00) including, but not limited to, motorcycles, RVs, and watercraft. (Click the plus sign to the right of each line to add as many vehicles as needed.)*YearMake/ModelPayoff amt If no vehicles are owned, please explain:Additional AssetsItemize below all Additional Assets. This includes, but is not limited to, ALL savings, retirement and college savings plans, investment accounts, rental property, additional land, business property and equipment, farm equipment, livestock, crops, etc... List all property by physical address. (Click the plus sign to the right of each line to add as many assets as needed.) List of AccountsClick the the plus sign to the right of the line below to add more accounts.Savings, Retirement, & College Savings Plans, Investments Accounts, etc...Market ValueLoan List of PropertyClick the the plus sign to the right of the line below to add more property.Rental Property, Business Property & Equipment, Farm Equipment, Livestock, Crops, etc...Market ValueLoan DebtsIn 'Debts', provide the total payoff balances for any additional bills you owe other than what is previously listed. Total of All Medical/Dental Bills (if none, type $0.00):*Total of All Credit Cards (if none, type $0.00):*Total of Other Outstanding Loans not listed in application (if none, type $0.00):* AcknowledgementBy completing this form and signing below, I acknowledge and agree to the following statements: This form is an application only. Completing this form does NOT guarantee the receipt of a Jones Foundation medical grant. The Jones Foundation reviews each application to determine whether the qualifications and eligibility for financial assistance have been met. The Foundation's Board of Trustees , in its sole discretion, has the final decision regarding the qualification, eligibility, and the amount of financial assistance to be awarded. All information provided in this application and its supporting documentation is true and accurate to the best of my knowledge and belief. I am providing this information voluntarily. I understand that intentional misstatements or falsification of the information in the application will render me immediately ineligible for the Jones Foundation medical grant. I certify that each child named in this application (i) is a United States citizen, (ii) is under the age of 21, (iii) resides in Coffey, Lyon, or Osage County and (iv) has continuously resided in Coffey, Lyon, or Osage County for no less than one year immediately prior to the date on this application. I will immediately inform the Jones Foundation if this information changes in any way. I understand that I must maintain residency in Coffey, Lyon, or Osage County to maintain eligibility for a Jones Foundation medical grant. I understand that failure to maintain residency in these counties may result in the immediate loss of the Jones Foundation medical grant, if awarded. All information provided in this application and its supporting documentation may be reviewed by the Jones Foundation staff and its Board of Trustees. I authorize the review of the information provided herein, including any protected health information, by the Jones Foundation staff and its Board of Trustees to determine eligibility for the medical grant. I authorize the Jones Foundation staff to contact those certain providers named in this application to verify or supplement the information provided in the application or supporting documentation. Restrictions on Use or Disclosure of InformationI request that the Jones Foundation NOT release to or discuss the information provided herein or attached with the following individuals:NameRelationship Electronic SignatureApplicant Father's Signature*Use your computer mouse or your finger (if using a smart phone or tablet) to draw your signature below:Applicant Mother's Signature*Use your computer mouse or your finger (if using a smart phone or tablet) to draw your signature below:Applicant Legal Guardian's Signature*Use your computer mouse or your finger (if using a smart phone or tablet) to draw your signature below:Applicant Signature - Required if Applicant is over the age of 18 as of the date of this Application.* Use your computer mouse or your finger (if using a smart phone or tablet) to draw your signature below:Date Date Format: MM slash DD slash YYYY * I understand that checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this document.
