Hospice Care Foundation | Compassionate Care Grant Application

Compassionate Care Grant Application

Thank you for your interest in our Compassionate Care Grants.

The 2019 application period is open December 1, 2018 through 3:00pm MST, February 1, 2019.

Organization Name*
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Is this the organization’s main office?*
- Yes
- No
Community(ies) Served*
Type of Organization*
Organization Type
If other, please enter organization type.
EIN*
Contact Information
Contact Name*
First Last
Contact Title
Phone*
Fax
Email*
Organization Information
TOTAL unpaid/unreimbursed bills for hospice/palliative care for calendar year 2018 (Jan-Dec):*
Amount requested from the Hospice Care Foundation:*
Other funding sources and amounts that applicant has or will seek to help defray these unpaid/unreimbursed costs:*
Funding Source Amount Requested Amount Received

Add additional rows by clicking the (+) sign.
Organization's Annual Operating Budget:*
Fiscal Year Begins*
In what year did your organization begin to offer services?*
Number of clients served by your organization in the last twelve (12) months?*
Number of indigent individuals served in the last twelve (12) months?*
(Note: Indigent individuals are defined as those who do not have insurance, private financials means and/or other ways to pay their hospice and/or palliative care bills in full.)
Percent of clients in the last twelve (12) months who are hospice/palliative care patients?*
How many clients received services during the last year in each service category below?
Pain & Symptom Control*
Spiritual Care*
Home Care*
In-Patient Care*
Respite Care*
Other
Please list “Other” types:
Expenses and Reimbursement Information
Please include a short explanation of what is included in each expense type listed.
In-Patient and Home Care (including pain & symptom control):
Short Explanation*
Expenses*
(for calendar year 2018)
Amount Unpaid/Unreimbursed*
(for calendar year 2018)
Spiritual Care:
Short Explanation*
Expenses*
(for calendar year 2018)
Amount Unpaid/Unreimbursed*
(for calendar year 2018)
Respite Care:
Short Explanation*
Expenses*
(for calendar year 2018)
Amount Unpaid/Unreimbursed*
(for calendar year 2018)
Other: (If applicable)
Short Explanation
Expenses
(for calendar year 2018)
Amount Unpaid/Unreimbursed
(for calendar year 2018)
Short Explanation
Expenses
(for calendar year 2018)
Amount Unpaid/Unreimbursed
(for calendar year 2018)
Short Explanation
Expenses
(for calendar year 2018)
Amount Unpaid/Unreimbursed
(for calendar year 2018)
Total Expenses
Total Amount Unpaid/Unreimbursed
Attachments
Annual Tax Return*
Accepted file types: pdf, doc, docx.
Please provide the organization's most recently completed tax return.
IRS Letter of Determination of Non-Profit Status
Accepted file types: pdf, doc, png, jpg, docx.
Required for 501(c)(3) Organizations
Verification of Expenses*
Accepted file types: pdf, doc, png, jpg, docx.
Please provide documentation verifying the unpaid/unreimbursed expenses for which you are seeking grant funding.
Signature
By signing below and submitting this form I certify that the above listed information is true and that the expenses for which we are requesting funding will not be paid/reimbursed.
Name*
Title*
Organization*
Contact Information
Questions may be directed to Kevi Berger at 406-541-2255 or kevi@hcfmissoula.com.

Last Revision Nov 2018

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Funding Source	Amount Requested	Amount Received