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MASSACHUSETTS BAPTIST CHARITABLE SOCIETY

Incorporated February 3, 1821, to aid the widows of the ministers of

The American Baptist Churches of Massachusetts, Clergy, and Clergy Families.

Rev. Rebecca Tornblom

57 Walnut Street

Holden, MA 01520-1335

Tel. 508-829-2788

massbaptistcharitable@gmail.com

GRANT APPLICATION FOR NON-REIMBURSED MEDICAL/PRESCRIPTION DRUG EXPENSES

Documentation must be included for the non-reimbursed medical/prescription drug expenses for which you are requesting a grant.

CONFIDENTIAL

 

Name:                                                                                                                                            Date:                                                                   

Address:                                                                                                                                                                                                                     

Telephone:                                                                    Email:                                                                                                                                   

Dependents-Please include names and ages:                                                                                                                                                         

                                                                                                                                                                                                                                       

                                                                                                                                                                                                                                       

Next of Kin or Whom to Contact in an Emergency:

Name:                                                                                                                                                Telephone:                                                           

 Address:                                                                                                                                                                                                                         

 Date of ABC/USA Ordination:                                                                                                                      Church:                                                    

Location and Dates of Service in Massachusetts:                                                                                                                                                       

                                                                                                                                                                                                                                             

                                                                                                                                                                                                                                            

Present Church Membership:                                                                                                                                                                                          

                                                                                                                                                                                                                                             

Describe the illness and/or condition for which the expenses were incurred.

                                                                                                                                                                                                                                             

                                                                                                                                                                                                                                              

                                                                                                                                                                                                                                               

Explain why expenses were not covered by insurance and/or Medicare/Medicaid.

                                                                                                                                                                                                                                                 

                                                                                                                                                                                                                                                 

Explain need for the grant:

                                                                                                                                                                                                                                                   

I certify that the above information is correct.

Signature of Applicant:                                                                                                                    Date:                                                                                   

Please return to: Douglas Tatreau 69 Fort Point Road North Weymouth, MA 02191

                                                                 If you have questions, please call me at: 781-664-4266              

Health Insurance Carrier:

Medicaid/Medicare:    Yes           No       Plan

 

CONFIDENTIAL