MASSACHUSETTS BAPTIST CHARITABLE SOCIETY
Providing aid to clergy and clergy families of the American Baptist Churches of Massachusetts since 1821
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Wendy Maxfield, Executive Secretary |
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Massachusetts Baptist Charitable Society Grant Application for Non-Reimbursed Medical/Prescription Drug Expenses ——Confidential—— Documentation must be included for the non-reimbursed medical/prescription drug expenses 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:_______________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Return your application and the supporting documentation to the Executive Secretary at: Massachusetts Baptist Charitable Society Attn: Wendy Maxfield PO Box 4003 Westford, MA 01886 If you have additional questions or need assistance with the forms, |
