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
for which you are requesting a grant.

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, 
call Wendy Maxfield at (978) 501-1310 or email to massbaptistcharitable@gmail.com.