DO I QUALIFY? To qualify for assistance from Ribbon Riders, you must meet the following criteria:

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1 Ribbon Riders, Inc. PO Box Lake Mary, FL Thank you for contacting Ribbon Riders regarding our Breast Cancer Assistance program. Please review the attached information prior to submitting your application. DO I QUALIFY? To qualify for assistance from Ribbon Riders, you must meet the following criteria: Live in Orange, Osceola, Seminole, Lake, Volusia, Brevard, Marion, Sumter, Flagler or Polk counties. Are currently in treatment for breast cancer. Demonstrate financial need and your household income must not exceed two times the federal poverty level. Please check the federal poverty level guidelines base on your household size. This is based on your CURRENT income (not what you used to make last year or before breast cancer). APPLICATION: Please fill in ALL INFORMATION in detail. DO NOT leave any lines blank. The second page requires your Doctor s office (or treatment center) diagnosis and signature in the appropriate lines. You will need to sign and date the HIPPA agreement. We cannot proceed without these signatures. FINANCIAL: Please send the required financial information: Three (3) months of checking/savings bank statements for each adult member of your household. Please send copies, not your originals. Proof of all total household income including the last three (3) paycheck stubs for each adult member of your household. (This includes the income of anyone living with you). Please include copies of any employment check stubs, food stamps, SSI, Unemployment, Medicaid/ Medicare & Child Support assistance. ASSISTANCE REQUESTED: Please include copies (not originals) of current bills you would like Ribbon Riders to consider for assistance. Please review our criteria for financial assistance to help you decide which bills to send. When you have all required documentation, please send to us by (assistance@ribbonriders.org), Fax ( ) or mail (PO BOX , Lake Mary, FL 32795) We will take all items into consideration and you will be contacted if we need further information. PLEASE NOTE: In order for your application to be considered, we must have ALL REQUIRED DOCUMENTATION as detailed above. If you have any questions, please contact us at assistance@ribbonriders.org or (PINK). Ribbon Riders, Inc.

2 Ribbon Riders Financial Guidelines To qualify for Ribbon Riders Financial Assistance, your household income must be under 200% of the Federal Poverty Level Guidelines. This is your CURRENT income, not income before breast cancer. To calculate your household income, you must include EVERYONE living in your household. This includes, spouses, children, roommates, friends, significant others, siblings, family members, etc. Your household income must not exceed: Maximum Members In Household Household Income 1 $ 23,340 2 $ 31,460 3 $ 39,580 4 $ 47,700 5 $ 55,820 6 $ 63,940 7 $ 72,060 8 $ 80,180 Additional Household members over 8 add $8120 per person Updated January 2014

3 RIBBON RIDERS BREAST CANCER ASSISTANCE FUND APPLICATION TELL US ABOUT YOURSELF: First Name: Last Name: Address: City: State: Zip: County: Home/Cell Phone: Work Phone: Address: Date of Birth: Marital Status: Names and Ages of anyone living in your household (include spouse, children, other family members, roommates etc): Do you or any member of your household receive food stamps? Yes No HELP US UNDERSTAND YOUR CURRENT FINANCIAL SITUATION: Do you or any member of your household receive disability income? Yes No Are you receiving or have you received/ applied for financial aid from any source? Yes No, If Yes please explain: INCOME: EXPENSES: Your Monthly Income $ Monthly Mortgage/Rent $ Total Family Income $ Groceries/Food $ Disability Income $ Utilities $ Social Security Income $ Cable/Phone/Internet $ Food Stamps $ Car Payments/Loan Payments $ Child Support $ Insurance $ Other Income $ Medical Expenses $ Other Income $ Other Expenses $ TOTAL MONTHLY INCOME: $ TOTAL MONTHLY EXPENSES: $ Please tell us how the Ribbon Riders Breast Cancer Assistance Fund can help you (use separate sheet of paper if you need more space): ****IMPORTANT: PLEASE INCLUDE COPIES OF RECEIPTS OR BILLS YOU WOULD LIKE ASSISTANCE IN PAYING*** Ribbon Riders Breast Cancer Assistance Fund Application, Revised July 2013, Page 1

4 HELP US UNDERSTAND YOUR NEEDS: Date diagnosed with breast cancer: Type/Stage: Where are you being treated? (Name of center/hospital) Treatment Received To Date: Additional Treatment Required: YOUR MEDICAL SUPPORT TEAM: (this section to be filled out by your doctor, nurse, or case worker) Doctor Name: Phone Number: Medical Diagnosis: Diagnosis Code: Comments/Additional Information: I have read and reviewed this completed application and to the best of my knowledge can confirm that this applicant is currently undergoing treatment for breast cancer. Name (Printed) Signature of Medical or Social Expert Date APPLICANT SIGNATURE: (applicant must sign and authorize release of confidential information) I hereby certify that all of the above information is accurate. I authorize the release of my name and proof of treatment from my medical team. I also understand that this information will remain private and confidential and will only be used in determining financial need for the disbursal of funds from Ribbon Riders, Inc. Breast Cancer Assistance Fund. Signature of Applicant SEND COMPLETED FORMS & SUPPORTING DOCUMENTATION TO: Ribbon Riders, Inc PO Box Lake Mary, FL PINK (7465) assistance@ribbonriders.org Fax: Date CHECKLIST: Do you have the following complete? Copies of CURRENT Bills for Consideration Medical Supporting Diagnosis & Signature Your Signature Last three months of bank statements (all accounts) Last three paycheck stubs (of all family members who work) PLEASE HELP US HELP OTHERS: How Did You Hear About Ribbon Riders Breast Cancer Assistance Fund? How Could We Be More Helpful? Other Comments or Suggestions: Ribbon Riders Breast Cancer Assistance Fund Application, Revised July 2013, Page 2

5 RIBBON RIDERS BREAST CANCER ASSISTANCE FUND VERIFICATION OF NO FINANCIAL ACCOUNTS A copy of this form must be completed by all household members over age 18 that do not have a financial account. The purpose of this form is to certify that I, residing at NAME ADDRESS do not have any checking accounts, savings accounts, money market accounts, certificate of deposit accounts, IRA accounts, Keogh accounts, retirement accounts and any other type of financial account. SIGNATURE DATE APPLICANT NAME UPDATED July 2013

6 RIBBON RIDERS, INC. CRITERIA FOR FINANCIAL ASSISTANCE Please read the information below before submitting an application. Policy: Determines how the organization (Ribbon Riders, Inc) administers funds to breast cancer patients in the central Florida area who have requested assistance from our organization. Purpose: This policy serves as a guide for Ribbon Riders, Inc, to process requests from applicants who submit a formal application requesting financial assistance. Our mission is to provide financial assistance to breast cancer patients to make their fight with breast cancer a little less challenging by helping with expenses they face due to treatment. Policy guidelines: 1. The breast cancer patient must complete the application in full including supporting documents demonstrating their financial need. 2. The applicant must be diagnosed with breast cancer, meet income guidelines and a resident the following Florida counties: Orange, Osceola, Seminole, Volusia, Lake, Brevard, Flagler, Marion, Sumter or Polk. 3. Each application can be submitted for a MAXIMUM of $1000 once per year (365 days), funds permitting. The amount of assistance provided per applicant is based on the financial need of the applicant, bills submitted and the amount of funds available. 4. Please note in order to help as many breast cancer patients as possible, the lifetime financial assistance maximum is $3,000, funds permitting. 5. The applicant must provide documentation supporting financial need. All financial information will be held in confidence. 6. The application will not be reviewed until ALL required documentation is received. 7. All applications will be reviewed by the executive board members of the Ribbon Riders, Inc, for approval. 8. Ribbon Riders, Inc, will make every effort to quickly respond to a request for assistance. We will notify the applicant within 14 days after the application has been submitted, whether or not their request was approved. Most applications are processed and approved within 7 days. 9. Ribbon Riders does not make partial bill payments. We cannot pay a portion of your rent/mortgage or other bill. Your rent/mortgage or other bill must be less than $1000 to be considered for payment. 10. Ribbon Riders reserves the right to approve or deny the request for assistance. All criteria and policies are subject to change. Ribbon Riders, Inc, Criteria For Financial Assistance, Revised July 2013, Page 1

7 Some examples that may qualify for assistance: a) Assistance with mortgage, rent, utilities, etc. b) Prescription co-pays, insurance or COBRA premiums, future treatment, etc. c) Grocery or gas gift cards Some examples that do not qualify: a) Bills over $1000 b) Past due medical bills Any expenses not listed above may be submitted for consideration and review by the executive board. Application process: Submit a completed Ribbon Riders, Inc, assistance application including all required paperwork (bills for consideration and financial information). The application may be submitted electronically, via mail or by fax. Ribbon Riders, Inc, PO Box , Lake Mary, FL PINK (7465) assistance@ribbonriders.org Fax: Ribbon Riders, Inc. is a 501(c)(3) non-profit organization with a mission to provide financial assistance to breast cancer patients in Central Florida. We are professional women with a passion for motorcycles and strive make a positive difference in our community. Ribbon Riders, Inc, Criteria For Financial Assistance, Revised July 2013, Page 2