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

How much do you spend each month on the following expenses?


Please tally the above costs

Medical & Insurance

Please tally the above costs


Please tally the above costs


Please tally the above costs