Pre-Qualification

First Name

Last Name

Gross Monthly Income

$

Number of Household Members

Balance of retirement/savings/home equity?

$

Are you a United States citizen?

Have you been diagnosed with pancreatic cancer?

Do you have a GoFundMe page for the patient?

Requirements for Assistance

Applicant must be a U.S. citizen
You must live in the United States
The application must be completed in full, including submitting all required documents.
*Original signatures, No faxes or copies of doctor signatures will be accepted.
Have an annual household income of less than 200% of the national poverty level [Show 2020 Income Levels]
Have no more than $5000 total liquid assets (cash, checking and/or savings, equity in your home, recreational vehicles, etc.)

2020 INCOME GUIDELINES (200% of Federal poverty guidelines)

Household Size	Weekly	Monthly	Annually

1	$ 490.77	$ 2,126.66	$ 25,520.00
2	$ 663.07	$ 2,873.33	$ 34,480.00
3	$ 835.38	$ 3,620.00	$ 43,440.00
4	$ 1,007.69	$ 4,366.66	$ 52,400.00
5	$ 1,180.00	$ 5,113.33	$ 61,360.00
6	$ 1,352.30	$ 5,860.00	$ 70,320.00
7	$ 1,524.61	$ 6,606.66	$ 79,280.00
8	$ 1,696.92	$ 7,353.33	$ 88,240.00
For each additional person in household, add			$ 4,480.00

Apply for Assistance

Title

Custom Title

First Name

Middle Name

Last Name

Suffix

Address

City

State

Postal Code

Email

Confirm Email

Password Add a password for this site so you can securely access your application portal in the future. Password must contain at least 8 characters, one uppercase letter, a number, and special character.

Confirm Password

Phone Number

Current Monthly Income

$

Household Size

Current Balance of Checking Accounts

Current Balance of Savings Accounts

Current Balance of Retirement Accounts (401K, IRA, Stocks, etc.)

Spouse/Partner Name

Do you have more than $5000 in liquid assets? (ATV, motorhome, second property, etc.)

Yes

No

How much is your monthly rent/mortgage payment?

$

Are you currently up to date on your rent/mortgage?

Yes

No

Are you currently receiving assistance from any other organizations?

Yes

No

Which organizations are you receiving assistance from?

Are you a US resident?

Diagnosis

Date of Diagnosis

Physician's Name

Physician's Phone Number

Additional Comments

Pre-Qualification

Pre-Qualification

Requirements for Assistance

2020 INCOME GUIDELINES

Apply for Assistance