Travel Assistance Application Name(Required) First Last Address(Required) City State / Province / Region Phone(Required)Retreat Assigned(Required)Carolina Beach, NCScottsdale, AZSt. John, USVITopsail Island, NCHatteras Island, NCSedona, AZOcean City, MDKey West, FLMarco Island, FLBlue Ridge, GAEmerald Isle, NCOrange Beach, ALDeep Creek, MDGrand Haven, MIMystic, CTLake Tahoe, CATybee Island, GAOak Island, NCMyrtle Beach, SCTelluride, CONorthern Outer BanksBuxton, NCCentral Coast, CANew Smyrna Beach, FLFort Morgan, ALMarital Status(Required)SingleMarriedDivorcedSeparatedWidowedYour Employment Status(Required) Currently Employed Retired Receiving Disability Benefits Currently Unemployed Eligibility Requirements (You Must Check Each Box to Confirm you Meet all Requirements)(Required) I have been Accepted for a Little Pink Retreat Currently in treatment for breast cancer or living with metastatic (Stage IV) breast cancer. Have a current annual household income at or below the Income Level chart below. Funding is only for participants and individuals approved for the retreat on the application and that are included on participant (or ex-spouse) tax returns. It does not include others attending that are not included on their returns. Income Eligibility Household Family Size (this is the number of people claimed on taxes including yourself)Income on Most Current Tax Form. If you file separately, please includes amounts for you and your spouse.Names of People attending Retreat and RelationshipPerson Attending Name First Last RelationshipSelfSpouse/PartnerSonDaughterOtherTax InformationIncluded on my TaxesIncluded on an Ex or Partner(s) TaxesFiles their own TaxesAdd Another Person Yes Person Attending Name First Last RelationshipSelfSpouse/PartnerSonDaughterOtherTax InformationIncluded on my TaxesIncluded on an Ex or Partner(s) TaxesFiles their own TaxesAdd Another Person Yes Person Attending Name First Last RelationshipSelfSpouse/PartnerSonDaughterOtherTax InformationIncluded on my TaxesIncluded on an Ex or Partner(s) TaxesFiles their own TaxesAdd Another Person Yes Person Attending Name First Last RelationshipSelfSpouse/PartnerSonDaughterOtherTax InformationIncluded on my TaxesIncluded on an Ex or Partner(s) TaxesFiles their own TaxesAdd Another Person Yes Person Attending Name First Last RelationshipSelfSpouse/PartnerSonDaughterOtherTax InformationIncluded on my TaxesIncluded on an Ex or Partner(s) TaxesFiles their own TaxesAdd Another Person Yes Person Attending Name First Last RelationshipSpouse/PartnerSelfSonDaughterOtherTax InformationIncluded on my TaxesIncluded on an Ex or Partner(s) TaxesFiles their own TaxesAdd Another Person Yes Person Attending Name First Last RelationshipSpouse/PartnerSelfSonDaughterOtherTax InformationIncluded on my TaxesIncluded on an Ex or Partner(s) TaxesFiles their own TaxesAdd Another Person Yes Person Attending Name First Last RelationshipSpouse/PartnerSelfSonDaughterOtherTax InformationIncluded on my TaxesIncluded on an Ex or Partner(s) TaxesFiles their own TaxesIf you are Divorced or File Separate, please list the name of the individual on which your taxes are filed on. You agree that your minor dependents who are not reflected on your taxes are included on another persons taxes and that your income/tax status is reflected for them.Name of Person who claims my children as dependent(s): First Last 1st 2 pages of Most Recent Tax Year Documentation. If you have a tax prep company file your taxes, this is NOT the first 2 pages of summary that they provide. This is the first two pages of your actual 990, etc. form.(Required)Max. file size: 50 MB.The only document that should be uploaded here is your Federal Tax form for the most recent year you have filed- Do NOT upload your W2!. If you would like to provide additional information for consideration by our committee please include in the Additional Documents Upload Section:Example of Additional Documentation. Your previous tax year you were working, but you have recently been put on disability decreasing your income for this year. Upload Previous W2 & Disability Benefit Documentation.Additional Documentation- Please make sure that you have uploaded documents for all adults in your household that will be attending (yourself, spouse). You do NOT need to include any tax information for an adult child that is attending college. For example, if you file separately from your spouse, you still need to upload your tax form and their tax form. Drop files here or Select files Max. file size: 50 MB, Max. files: 4. I am applying for the following travel assistance based on my distance from the retreat location. Google your home address and the town name for your retreat location. These numbers will be verified prior to your acceptance. All eligible and approved families driving 0 - 300 miles 1 way qualify to receive a total $150 stipend All eligible and approved families driving 301 - 450 miles 1 way qualify to receive a total $250 stipend All eligible and approved families driving 451 - 600 miles 1 way qualify to receive a total $400 stipend All eligible and approved families driving over 601 miles 1 way qualify to receive a total $500 stipend Couples For Couples retreat to St. John, USVI ONLY, All eligible and approved will be awarded $1,000 total per couple. Agreement(Required)I understand that travel assistance funding is designated as restrictive use funding and as such, these funds should only be used solely to aid in my travel to and from the retreat location. Little Pink Houses of Hope, its employees, and agents are hereby authorized to obtain and discuss medical, treatment, therapy, financial, and other information relating to the applicant with the applicant’s healthcare providers, employer, and/or any other person or entity working with Little Pink Houses of Hope on the applicant’s behalf for purposes of confirming the applicant’s eligibility for the Travel Assistance Program. Little Pink Houses of Hope may also use or disclose the applicant’s personal information as necessary to provide applicants with assistance under the program. Little Pink Houses of Hope may anonymize and deidentify applicant information and data and use such information for Little Pink Houses of Hope's own purposes, including developing aggregate reports. Neither Little Pink Houses of Hope nor any of its employees or agents will disclose any applicant identifiable information to any third party except as provided above, as required by law, or as deemed appropriate by Little Pink Houses of Hope to investigate or resolve any potential fraud or audit irregularity. I also attest that all tax and financial information provided is accurate and legally binding. I will not hold Little Pink liable or responsible for any accidents, death, dismemberments that may occur while using the travel fund reward. I consent to the Agreement.
