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.

Mr. Douglas Tatreau

69 Fort Point Road

North Weymouth, MA 02169

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:                                                                                   

Wendy Maxfield, Executive Secretary

P.O. Box 4003, Westford, MA 01886

(978) 501-1310

massbaptistcharitable@gmail.com

Health Insurance Carrier:

Medicaid/Medicare:    Yes           No       Plan

CONFIDENTIAL