Financial Assistance Application

Confidential application for charitable financial assistance.

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Complete this confidential application to request charitable financial assistance. Required fields are marked with *. You may leave any section that does not apply to you blank. All information is used solely to consider your request and is kept confidential.

Applicant Information (Master Mason / Order of the Eastern Star Member)

First Name*

Last Name*

Middle Initial

Home Address

Street Address

City

State

Zip

Email*

Home Phone

Cell Phone

Date of Birth

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Marital Status Married Single Divorced Widowed

Home Lodge / Chapter

Date of Marriage

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If marriage terminated — when

Spouse Information

Spouse First Name

Spouse Last Name

Spouse Middle Initial

Spouse Date of Birth

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Spouse Date of Death (if applicable)

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Spouse Home Lodge / Chapter

Spouse Email

Other Persons Residing in the Home

Name	Relation	Date of Birth

Does anyone in the household have any of the following benefits? (check all that apply) Social Security Medicare Veteran's Affairs (VA) Medicaid

Facility Information

Facility Name

Facility Address

Street Address

City

State

Zip

Facility Administrator's Email

Facility Phone

Facility Fax

Applied for Medicaid / NJ FamilyCare? Yes No

Long Term Care Insurance? Yes No

Power of Attorney / Alternate Contact

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Please attach a copy of the relevant documents (you can upload them below).

POA First Name

POA Last Name

Relationship

POA Address

Street Address

City

State

Zip

POA Email

POA Home Phone

POA Cell Phone

Financial Power of Attorney? Yes No

Medical Power of Attorney? Yes No

Attach Power of Attorney / supporting documents

Attach file (.pdf, .jpg, .jpeg, .png, .doc, .docx) — max 25 MB

Optional. Attach POA documents or any other supporting paperwork.

Veteran's Information

Applicant — Branch of Service

Spouse — Branch of Service

Applicant — Dates of Service

Spouse — Dates of Service

Applicant — Conflict / War Era

Spouse — Conflict / War Era

Applicant — Retired? Yes No

Spouse — Retired? Yes No

Applicant — Applied for VA Benefits? Yes No

Spouse — Applied for VA Benefits? Yes No

Requested Assistance

Describe your current living arrangement, the health status of everyone in the household, the cause of your financial crisis, and your long-term plan to reach financial sustainability

What assistance are you requesting?

Have you previously requested assistance? Yes No

Have you previously received assistance? Yes No

If you previously received assistance, have you since received any inheritances, monetary gifts, back pay from approved benefits, compensation/settlement payments, or won/been given any large sums of money? Yes No

If yes, please provide details

Medical Information — Applicant

Applicant — Medical Concerns & History

Diagnosis / Injury	Treatment / Surgery / Medication(s)

Applicant — check all that apply Hearing Aids Dentures Walker/Wheelchair Glasses

Medical Information — Spouse

Spouse — Medical Concerns & History

Diagnosis / Injury	Treatment / Surgery / Medication(s)

Spouse — check all that apply Hearing Aids Dentures Walker/Wheelchair Glasses

Dependent Children in the Household — Medical Concerns & History

Dependent Children — Medical Concerns & History

Child's Name & Diagnosis / Injury	Treatment / Surgery / Medication(s)

Health Insurance

Name	Provider & Type of Coverage

Assets — Checking Accounts

Checking Account(s)

Bank	Ownership	Balance ($)

Assets — Savings Accounts

Savings Account(s)

Bank	Ownership	Balance ($)

Assets — Investment Accounts

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Retirement accounts, stocks, bonds, CDs, etc.

Investment Account(s)

Type of Investment Account	Ownership	Balance ($)

Assets — Life Insurance

Life Insurance

Policy (whole / term)	Beneficiary	Face Value ($)	Cash Value ($)

Do you have a pre-paid burial? Yes No

If yes, with whom?

All other assets (money market accounts, accounts receivable, promissory notes, security interests, and any gifts or inheritances expected in the future)

Real Estate

Property Address

Street Address

City

State

Zip

Titled to

Date Purchased

Estimated Value ($)

Mortgage Company

Escrow? Yes No

Principal Balance Owed ($)

Plan for the property

In residence? Yes No

Taxes Current Past-due

Do you own real estate other than listed above? Yes No

Additional Real Estate

Additional Property Address

Street Address

City

State

Zip

Additional — Titled to

Additional — Date Purchased

Additional — Estimated Value ($)

Additional — Mortgage Company

Additional — Escrow? Yes No

Additional — Principal Balance Owed ($)

Additional — Plan for the property

Additional — Taxes Current Past-due

Vehicles

Year / Make / Model	Mileage	Lender	Debt Balance ($)

Other Vehicles / Personal Property (RV, trailers, boats, tractors, etc.)

Other Vehicles / Personal Property

Year / Make / Model	Value ($)	Mileage	Lender	Debt Balance ($)

Debts — Personal Loans & Past-Due Balances (utilities, taxes, etc.)

Personal Loans & Past-Due Balances

Creditor	Monthly Payment ($)	Balance Due ($)

Debts — Credit Cards

Credit Cards

Creditor	Monthly Payment ($)	Balance Due ($)

Debts — Medical Bills

Medical Bills

Provider	Monthly Payment ($)	Balance Due ($)

Monthly Income

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Enter monthly amounts for the applicant and spouse where applicable.

Employment — Applicant ($/mo)

Employment — Spouse ($/mo)

Social Security / Disability Income — Applicant ($/mo)

Social Security / Disability Income — Spouse ($/mo)

Retirement / Pension — Applicant ($/mo)

Retirement / Pension — Spouse ($/mo)

Medicaid / NJ FamilyCare — Cash Grant / Personal Spending — Applicant ($/mo)

Medicaid / NJ FamilyCare — Cash Grant / Personal Spending — Spouse ($/mo)

Blind Pension — Applicant ($/mo)

Blind Pension — Spouse ($/mo)

Public Assistance — TANF / Food Stamps / WIC / etc. — Applicant ($/mo)

Public Assistance — TANF / Food Stamps / WIC / etc. — Spouse ($/mo)

Lodge / Chapter / Community Assistance — Applicant ($/mo)

Lodge / Chapter / Community Assistance — Spouse ($/mo)

Child Support — Applicant ($/mo)

Child Support — Spouse ($/mo)

Monthly Expenses

Groceries / Snacks ($/mo)

Mortgage / Rent ($/mo)

Electric ($/mo)

Gas ($/mo)

Water / Sewer / Trash ($/mo)

Telephone — landline ($/mo)

Telephone — cell ($/mo)

Internet ($/mo)

Cable / Dish / Media Subscriptions ($/mo)

Prescription Medication ($/mo)

Over-the-Counter / Diabetic / Incontinence Supplies ($/mo)

Health Insurance ($/mo)

Homeowners / Renters Insurance ($/mo)

Specialty Insurance (Long-Term Care, AFLAC, etc.) ($/mo)

Life Insurance ($/mo)

Burial Plan ($/mo)

Car Payment(s) ($/mo)

Car Insurance ($/mo)

Gasoline ($/mo)

Beauty Shop / Barber Shop ($/mo)

Other ($/mo)

Type of domicile (for Mortgage / Rent)

Number of cell phone lines

Number of vehicles covered by car insurance

Additional Information

Within the past five (5) years, have you tithed or made monetary gifts, loans, or transfers of real estate, personal property, investments, stocks, or bonds? Yes No

If yes, please provide details of those transfers and/or gifts

Please share anything else pertinent to your request or that you would like the Board of Directors to know

Applicant Agreement & Certification

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I/we hereby apply for financial assistance from the Masonic Charity Foundation of New Jersey, a New Jersey nonprofit organization. I/we understand and agree that this document does not constitute a contract for the provision of assistance, and that any assistance provided is under the charitable guidelines of the Masonic Charity Foundation of New Jersey.

I/we authorize the disclosure of all information, documents, and reports contained in or submitted with this application, together with any additional information furnished to the Masonic Charity Foundation of New Jersey, for consideration, discussion, and decision-making by current and future staff and the officers of the Board of Directors.

I/we understand that Masonic Charity Foundation of New Jersey staff have no authority to bind the Foundation to the approval or denial of assistance. All requests for assistance are approved by authorization of the Board of Directors.

Applicant Agreement — key terms:

As a condition of assistance, I agree to sign a Loan Agreement; my ability to repay is based on current or future assets and/or income.
If I own real property, the Loan Agreement may be secured by a Deed of Trust; repayment includes only the amount expended on my behalf and is repaid at the time of sale.
The Foundation supports only the property where I reside, not additional properties, which I may be expected to sell to spend down assets.
Upon approval, I agree to make the Foundation the beneficiary of my life insurance policies to ensure repayment (except an irrevocable prepaid-burial policy already payable to a funeral home).
I agree not to give away property, assets, or income; gifting within the last 5 years can make me ineligible.
The Foundation typically supports up to 21 hours of in-home care per week; greater needs likely require transition to a senior community.
Monthly/repeated assistance requires periodic reassessment (not to exceed 6 months without reassessment) and complete, accurate financial documents.
Concealment, disposal, or transfer of assets to avoid disclosure, or any misrepresentation, is sufficient reason to reject or terminate assistance.
I have a continuing obligation to seek all public/private benefits I am eligible for (e.g., VA, Medicaid) and may be asked to lower expenses where a more affordable option exists.
Assistance may be conditioned on my active participation in the Financial Coaching and Education Program.
I agree not to incur additional debt while receiving assistance without prior Board approval.
The Foundation will not pay off credit-card debt; if asked, I agree to close credit-card accounts and not open new ones.
If I reside with family/friends, support covers only my share of household costs.
I agree to notify Foundation staff immediately of any move, hospitalization, change in finances, income, debt, expenses, or marital status, or any unexpected expense.

I/we acknowledge receipt of the Applicant Agreement and agree to the requirements of the Masonic Charity Foundation of New Jersey's Financial Assistance Programs.

I have read, understand, and agree to the Applicant Agreement above.* I have read, understand, and agree to the Applicant Agreement above.

I certify that all information in this application is accurate to the best of my knowledge.* I certify that all information in this application is accurate to the best of my knowledge.

Applicant signature (type your full name)*

Spouse signature (type full name, if applicable)

Date*

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