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
Phone: 508-829-2788 Fax: 774-345-4148
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.
Dependents-Please include names and ages:
Next of Kin or Whom to Contact in an Emergency:
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: Rev. Becky Tornblom, Executive Director, 57 Walnut Street, Holden, MA 01520
If you have questions, please call me at: 508-829-2788
Health Insurance Carrier:
Medicaid/Medicare: Yes No Plan