Elizabeth White Lyme Patient Grant

Elizabeth White Lyme Patient Grant is sponsored by Lyme Connection (through The Community Foundation for Greater New Haven). The Elizabeth White Fund supports qualified Lyme patients in Connecticut with medical expenses related to testing and care.

## The Community Foundation for Greater New Haven ## Elizabeth White Fund for Lyme Disease Applicants must complete the attached application and provide all requested supportive documents. Any household or family who is at or below 85% of the State Median Income or is participating in state or Federal Assistance programs should consider  Proof of State/Federal assistance (HUSKY, MSP, SNAP, Energy assistance etc.).

 Most recent (2 months) bank statements for all bank accounts > Applications can be mailed to: ## The Community Foundation for Greater New Haven ## Elizabeth White Fund for Lyme Disease Please submit application to: YOU MUST BE A CT RESIDENT TO APPLY Families who are at or below 85% of the State Median Income level or participate in State or Federal assistance programs should consider applying .

NAME_______________________________________DOB_____________ DATE______________ PHONE _________________________ EMAIL___________________________________________ ADDRESS____________________________________________ How Long at Address___________ Married__________ Single _________ Divorced ________ Widowed ___________ Number of People living with you: Adults ___________ Children __________________ Name and of Employer ________________________________________ Date Employed ___________ Address of Employer __________________________________Employer Phone Number ___________ Are you/family member disabled?

______________________________________ Date of Disability _______ PLEASE SUBMIT THE FOLLOWING DOCUMENTS FOR THE LAST 2 MONTHS : Verification of all income Bank statements for all accounts Proof of State or Federal assistance 2 PLEASE COMPLETE THE FOLLOWING: Rent/Mortgage Employment Homeowners/rental Insurance SS Electricity SSD/SSI Heat Alimony/Child Support Cable Pension Auto Stocks Auto Insurance Unemployment Food Family/Friends Health Insurance Other Medical Bills (outstanding) Other Please provide any additional information you would like to include on reverse side.

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