Medical Grant Application "*" indicates required fields Step 1 of 6 16% Are you applying for yourself or your child?* Self Child What type of help is needed?*You may select more than one. General Medical Expenses Dental Expenses Medically Necessary Orthodontics (Braces) Eye Exams and Corrective Lenses Is applicant a US Citizen or non-US Citizen with Lawful Immigration Status or Permanent Resident?* Yes No Is applicant under age 21?* Yes No In which county does applicant reside?* Coffey County, Kansas Lyon County, Kansas Osage County, Kansas Elsewhere Has applicant resided in Coffey, Lyon, or Osage County continuously for a minimum of one year?* Yes No Applicant is not eligible. Applicant 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 PageYou've met the eligibility requirements to apply. Please click Next to proceed to the application.There are additional eligibility requirements for braces. You'll be asked some additional questions about braces on the next screen.HIDDEN. Assistance type selected from previous page. Greater than 1 means than more services than just braces were selected. Braces Eligibility AssessmentIs applicant under age 19?*Child must be under age 19 for orthodontics Yes No Has applicant received braces from the Jones Foundation in the past?* Yes No Is applicant currently wearing braces?* Yes No Has applicant been seen by a Board Certified Orthodontist? (An orthodontist is different than a dentist. They specialize in braces and the position of teeth and jaw.)* Yes No Did your Orthodontist tell you that braces were Medically Necessary and to apply to the Jones Foundation?* Yes No HIDDEN. Braces eligibility. Correct answers give 2 points. Must = 10 for eligibilityApplicant is not eligible for braces Applicant must be under age 19, currently not wearing braces, have never received braces in the past from the Jones Foundation, and MUST have been seen by a board certified orthodontist who deemed the braces medically necessary. Return to Home PageApplicant IS NOT eligible for braces, but IS ELIGIBLE for other medical or dental assistance. To continue with the application for other medical or dental assistance, click Next.You've met the eligibility requirements. Please click Next to proceed to the application. Referred by:Is this your first time applying?* Yes No If yes, how did you hear about us?Applicant's InformationApplicant's Name* First Middle Last Applicant's Age*Applicant's Date of Birth* Applicant's Gender*Applicant's Last 4 Digits of Social Security #*Applicant's Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Applicant's Daytime Phone*Applicant's Email* Applicant Employer*How long have you worked for this employer?* Less than one year One year or more Hourly wage*Hours worked per week*Pay frequency*Please select:WeeklyBi-WeeklyMonthlySemi-MonthlyNumber of years applicant has resided in Coffey, Lyon or Osage County:*Applicant Marital Status* Single (never been married) Married Living together Divorced Separated Widowed Do you have other children who ALSO need assistance that you'd like to include on this application? Yes No Other children needing assistance:Additional ChildAdditional Child's Name First Middle Last AgeDate of Birth GenderLast 4 Digits of Social Security # Add Additional Child Remove Additional Child Additional Child 1Additional Child's Name First Middle Last AgeDate of Birth GenderLast 4 Digits of Social Security # Add Additional Child Remove Additional Child General Medical InformationWhat medical treatment was received or needed? Please provide DETAILED information.*List all Medical Providers. Click the Add Provider button to add more if needed.ProviderMedical Provider Name*Date of Medical Services* Add Provider Remove Provider Provider 1Medical Provider Name*Date of Medical Services* Add Provider Remove Provider Does applicant have medical insurance?* Yes No Medical Insurance Name:*Dental InformationWhat dental treatment was received or needed?*List all Dental Providers. Click the Add Provider button to add more if needed.ProviderDenal Provider Name*Date of Dental Services* Add Provider Remove Provider Provider 1Denal Provider Name*Date of Dental Services* Add Provider Remove Provider Orthodontics InformationOrthodontist's Name*Date of First Orthodontic Visit*Does applicant have dental insurance?* Yes No Dental Insurance Name:*Vision InformationEye Doctor's Name*Eye Doctor's Location*Business Name & Location where you will purchase glasses?*Does applicant have vision insurance?* Yes No Vision Insurance Name:*Does vision insurance cover eye exams?* Yes No Does vision insurance cover glasses?* Yes No Custodial Parent/Legal Guardian Household Information:Parent/Legal Guardian Marital Status* Single (never been married) Married Living together Divorced Separated Widowed Parent/Guardian Name* First Last Relationship to Child* Mother Father Legal Guardian Parent/Guardian Address* Street Address City State ZIP Parent/Guardian Daytime Phone*Parent/Guardian Email* Parent/Guardian Employer*How long has parent/guardian worked for this employer?* Less than one year One year or more Parent/Guardian hourly wage*Parent/Guardian hours worked per week*Parent/Guardian pay frequency*Please select:WeeklyBi-WeeklyMonthlySemi-MonthlyContact name for household information questions*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*How long has spouse/partner worked for this employer?* Less than one year One year or more Spouse/Partner hourly wage*Spouse/Partner hours worked per week*Spouse/Partner pay frequency*Please select:WeeklyBi-WeeklyMonthlySemi-Monthly Income & Tax Questions (if applicable)If you do not file taxes, what is your reason?If your child 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 IncomeIn the previous year, if you, your parents or anyone in the household received any of the income listed below, provide the total amount received from January 1 through December 31, enter below and include proof of total amounts received.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):*Home and VehiclesDo 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 are you purchasing a vehicle or vehicles of any kind, including but not limited to, cars, trucks, SUVS, vans, RVs, motorcycles or watercraft? Yes No VEHICLES: List below ALL vehicles (even if amount owed is $0.00) including, but not limited to, motorcycles, RVs, and watercraft. Click the Add Vehicle button to add more.VehicleVehicle Year*Make & Model*Payoff Amount (if none, type $0.00)* Add Vehicle Remove Vehicle Vehicle 1Vehicle Year*Make & Model*Payoff Amount (if none, type $0.00)* Add Vehicle Remove Vehicle If no vehicles are owned, please explain:Additional AssetsItemize below all Additional Assets. ACCOUNTS: List ALL savings accounts, retirement accounts, college savings plans, investment accounts, etc. Click the Add Account button to add more.AccountAccount Type (if none, type NONE)*Account Value (if none, type $0.00)*Loan, if any (if none, type $0.00)* Add Account Remove Account Account 1Account Type (if none, type NONE)*Account Value (if none, type $0.00)*Loan, if any (if none, type $0.00)* Add Account Remove Account PROPERTY: List ALL additional property owned, including rental property, land, business property, business equipment, farm equipment, livestock, crops, etc. Click the Add Property button to add more.PropertyProperty Type (if none, type NONE)*Market Value (if none, type $0.00)*Loan, if any (if none, type $0.00)* Add Property Remove Property Property 1Property Type (if none, type NONE)*Market Value (if none, type $0.00)*Loan, if any (if none, type $0.00)* Add Property Remove Property 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 InformationOPTIONAL: I request that the Jones Foundation NOT release to or discuss the information provided herein or attached with the following individuals: Name of Restricted IndividualRelationship to applicantElectronic SignatureParent/Legal Guardian's Signature*Use your computer mouse or your finger (if using a smart phone or tablet) to draw your signature below:Your NameYour NameYour NameYour NameApplicant 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:Your NameYour NameYour NameYour NameDate * 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.
