Application

2Check List

Check List

Thank you for requesting information from The CAUSE Foundation. This checklist is provided to assist you in filling out your application. Please initial as each item as you read it, sign it below and return it with your completed application. Failure to return this checklist will delay the processing of your grant application.

Once your application is approved, it is your responsibility to contact your domicile CAUSE Representative by the 5th of each month regarding your grant continuation. Failure to do so will result in no funds issued for that month. In addition, a review of an ongoing application will occur every three months. Updated documentation is required at least every six months or as requested. *

0 of 3 max characters.

An application form must be filled out completely and signed by the applicant and CAUSE Representative. The “Amount Requested” space must be filled in. Monetary amounts must be stated in US currency. *

0 of 4 max characters.

Current medical documentation signed by your doctor must accompany the application or be sent to the CAUSE Representative. It is your responsibility to provide updated documentation every six months. (Please contact your CAUSE Rep for process of getting this information to us.) *

0 of 4 max characters.

Copies of both the 1st and 16th paycheck stubs for the previous two months prior to your last day worked must accompany your application. *

0 of 3 max characters.

Copies of spouse’s/domestic partner’s (if applicable) paycheck stubs for the previous two months must accompany your application. *

0 of 3 max characters.

Copies of all pages of your bank statements for the past two months must accompany your application *

0 of 3 max characters.

A copy of your most recent 401K Statement must accompany your application *

0 of 3 max characters.

Documentation of sick leave balance must accompany your application. *

0 of 3 max characters.

Copies of federal income tax returns (Form 1040) for the previous two years must accompany your application. W-2’s do not constitute tax returns and will not be accepted as such. The CAUSE Foundation reserves the right to request further financial documentation. *

0 of 3 max characters.

If you are single/divorced with dependent children and not receiving child support, a copy of the divorce decree and custody agreement with child support agreement must accompany your application. *

0 of 3 max characters.

If this application is related to a work related injury, copies of appropriate documentation (accident report, pay stubs and check copies, including Workers Comp checks) must accompany the application. *

0 of 3 max characters.

If you are in litigation in conjunction with the illness or injury listed on this application and receive a settlement, it would be appreciated if you would consider making a donation to The CAUSE Foundation so that we may continue to help other flying partners in need. *

0 of 3 max characters.

All applications must have the appropriate documentation in place before checks can be issued. No exceptions! Please make copies of all paperwork for your personal file. *

0 of 4 max characters.

Signature

Clear Signature

Please enter your CAUSE Rep's name that you have been working with (If you have not contacted a Rep please do so prior to continuing.) *

Save and Resume Later

MONTHLY INCOME (US $$)

If you don’t have any income in a certain category please put a 0 (zero)

The CAUSE Foundation certifies that any and all information obtained to support this application will be kept confidential by the persons signing this application and their officers.

It is the policy of The CAUSE Foundation to review each grant application without regard to an individual’s race, creed, color, religion, sex, age, national origin, nature of disability or sexual orientation.

Current United (NET) *

Please upload your last 2 (two) months pay stubs from United (when you actually worked). *

Click or drag files to this area to upload. You can upload up to 4 files.

Files accepted are pdf, png, gif, and jpg

Social Security Disability *

State/Foreign Disability *

Short Term Disability *

Long Term Disability *

Alimony/Child Support *

If you are NOT receiving your court awarded child support, please attached documentation explaining what steps you are taking to pursue collection.

Please provide a copy of the divorce decree and custody agreement with child support agreement if you are single/divorced with dependent children and not receiving child support

Click or drag files to this area to upload. You can upload up to 3 files.

Files accepted are pdf, png, gif, and jpg

Additional Income *

Pension Income *

Social Security Income *

Signature *

Clear Signature

I, the undersigned, certify that all of the statements and representation of this application constitute a true and accurate account of my illness/disability and financial condition as of the date below. I have attached, in support of this application, requested documentation. Fraudulent use of The CAUSE Foundation will cause forfeiture of all future benefits and may result in criminal and/or civil litigation and prosecution. Additionally, CAUSE will investigate all possible avenues of recouping monies obtained under false pretenses.

I, the undersigned, on my behalf or as guardian of another, authorize THE CAUSE Foundation to release information to its Board of Directors, employees and volunteers as necessary with regard to my grant application. I give the above authorization with the recognition of my privacy rights under the Health Insurance Portability and Accountability Act and the Final Rule promulgated under HIPAA, 45 CFR Parts 160 and 164.

Other Income (be specific)

Other Income Amount

Save and Resume Later

Check List

THE CAUSE FOUNDATION APPLICATION FOR GRANT

MONTHLY INCOME (US $$)

ASSETS

MONTHLY EXPENSES

Miscellaneous