The Kidney Transplant/Dialysis Association, Inc.

PO Box 51362 GMF ~ Boston, MA 02205

www.ktda.org - 781-641-4000

The Kidney Transplant/Dialysis Association, Inc.
PO Box 51362 GMF - Boston, MA - 02205-1362 - 781 641-4000 Fax 781 272-0558

Instructions: Please answer all questions. PLEASE PRINT. Incomplete applications will not be processed.

Supply the names of creditors who are to be paid or reimbursed. Please submit legible bills or receipts.

Return completed application to your Social Worker, who will fill review the last section with you.

Please submit all supporting documents to or fax 781 658-2088 (fax not regularly monitored)

Applicant
Name / Age _____ / Marital Status(circle one) Single Married Separated Divorced Widowed
Address: / Number in Household / Total Income
(including applicant) # $
City: / State / Zip Code:
Home Phone ______Mobile ______E-mail ______
I am a (circle one) Dialysis Patient Transplant Recipient Kidney Donor
If not Applicant (i.e. Parent/Guardian/Care Giver) Name______
Applicant Insurance (circle one) Medicaid Medicare TriCare Other______
Employed (circle one) Yes No If Yes, Number of Years ______
Employer Name ______City, ST Zip: ______
If No (circle one) Minor (<18) Student Disabled Unemployed Retired Other (specify)______
TO BE FILLED OUT BY SOCIAL WORKER
Amount of Request $______Payable to______
Name (Social Worker) / Name of Facility
Address (city State & Zip):
Phone ______/ E-Mail______
Purpose of Grant (description of patient/recipient and financial need): ______
______
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The Kidney Transplant/Dialysis Association, Inc.

Monthly Net Income (before Taxes) / Monthly Expenses
Wages / Rent or Mortgage
Spouses Wages / Heat included Yes/No
Wages of Others / Food
Disability / Utilities
Social Security / Electric
Welfare / Oil/Gas
SSI / Water
Medicaid / Phone
Pension / Property Taxes
VA Benefits / Auto
AFDC / Auto Payment
Other / Other
Monthly Medical
Doctor/Dentist
Total Income $ / 0 / Hospital
Medications
Assets / Insurance
Home Own or Rent / Medical
Checking ______/ Life
Savings ______/ Auto
Investments ______/ Other
Other______/ Credit Cards
Loans
Other (specify)
Other (specify)
Total Assets $______ / Total Expenses $
If Principle Wage Earner is NOT the Applicant-Please Complete The Items Below
Name ______Relationship (to Applicant) ______Monthly Income (Before Taxes) ______
Employer Name ______Address (City, ST Zip): ______

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The Kidney Transplant/Dialysis Association, Inc.

My signature below acknowledges and grants permission for the following:

1.  KTDA has permission to provide this application and any supporting documentation to the PAC Committees members for review, consideration for approval and if applicable payment processing

2.  KTDA has permission to add my contact info to the electronic members list. This will provide KTDA the ability to send organizational updates. KTDA does do not sell or share your contact information with any third parties

3.  I certify I have reviewed the above information for eligibility and accuracy

4.  I certify the information supplied is accurate to the best of my knowledge

5.  Submittal of this application by the herein referenced Social Worker does not release the applicant from the conditions above

Applicant Signature / Date

REMINDER: Submit completed application form and all supporting documents to your Social Worker

Social Worker Signature ______Date______
FOR KTDA ONLY
DATE: Rcvd____ Sent for Review_____ Approved/Declined_____ SW notifications _____ Piad______
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