We Are Glad To Be Moving Your Application Forward!

Please fill out the following form. On the second page, there is a place to upload the requested verifying documents. These may also be emailed to us at info@wvcancerfoundation.org or dropped off at our office at your convenience.

Documents we require are:

  • Cancer diagnosis from a physician
  • Proof of income for every adult in your household including tax returns, pay stubs, Social Security Letters, or other sources of income
  • Proof of expenses which may include utility bills, rent or mortgage statements, credit card statements, insurance premium statements, personal expenses, car payment, or other monthly expenses

Documents to also include if applicable to you:

  • Health insurance certificate showing deductible and annual maximum
  • Current bank statements for all checking, savings, and investment accounts in your name

Please note all entries are required. If an item listed does not fit your current situation, please the number 0 (zero) on the form.

Please include wages, unemployment, social security, retirement, disability, child support, alimony, interest/dividends, TANF/SNAP benefits, or other income
Please include wages, unemployment, social security, retirement, disability, child support, alimony, interest/dividends, TANF/SNAP benefits, or other income