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

Email: beckytornblom@msn.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: 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

CONFIDENTIAL