Assistance Request Form

All fields with an * must be filled in

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Please attach required doctors/social worker/case worker letter confirming intended assistance recipients medical diagnosis and need.

Click or drag a file to this area to upload.

Your Name (Name of person filling out this form)

First

Last

Phone number of person filling out this form

Email of person filling out this form

Are you applying for yourself, or on behalf of someone else?

Applying for myself
Applying on behalf of someone else

If applying for someone else, what is their relationship to you?

Date of birth of intended recipient

Address of recipient/guardian

Address Line 1

Address Line 2

City

State

Zip Code

Email of recipient/guardian

Confirm Email

Phone number of intended recipient/guardian

Amount of assistance request (estimated dollar amount- not a range)

Description of item/services to be purchased- Please be specific and be prepared to provide proof of need

How does this item/service fall in line with Granite State Generosity's mission to help those with life changing and life threatening diseases and disabilities, in NH?

If you are submitting this form and are NOT a social worker or part of the intended recipients medical team, please provide the name and either e-mail or phone number of your social worker

Acknowledgement (please check in agreement)

I understand that completion of this request DOES NOT guarantee that assistance will be provided
To the best of the submitters knowledge, the proposed recipient is experiencing financial hardship