Spare Key Mortgage Assistance Application UPDATED January 1, 2016 Thank you for your interest in Spare Key s Mortgage Grant Assistance Program. Any questions regarding the application or guidelines may be directed to Nikki by phone at (952) 406-8872 or email at nikki@sparekey.org. BEFORE YOU BEGIN, PLEASE READ THE FOLLOWING: Please read the Spare Key Program Guidelines before completing the application to be sure your family is eligible. (Guidelines can be found at www.sparekey.org.) Completion of this application does not guarantee approval of a mortgage grant. Any incomplete applications will not be considered and will be DENIED. Applications are received once a month and must be received or postmarked before the first of the month to be considered in the next month s review cycle. Families will be notified by phone or writing by the 25th of the month. (Please see the Spare Key Program Guidelines for the Grant Review Schedule.) Spare Key receives no public or government funds for its program. All funds are donated by private sources including but not limited to individuals, foundations, companies, corporations, and through events supported by thousands of generous individuals each year. Until written notification is received from Spare Key, no assumption of payment should be made. Applications can be mailed to: Applications can be scanned and emailed to: Spare Key nikki@sparekey.org Attn: Nikki 2021 E. Hennepin Ave. Suite 475 Applications can be faxed to: 952-406-8874 Minneapolis, MN 55413 Personal Information: Child s Name (First & Last): Child s Date of Birth: / / Child s Gender: Are you a previous Spare Key grant recipient? Yes No If yes, when? Parent(s)/Legal Guardian(s) Name(s): Address: City: State: Zip Code: County: Home Phone/Cell: Cell: Email Address: Please share your Family/Child Website: (CaringBridge, Care Pages, Facebook, etc.) Total number of household residents: Age(s) of other children living at home: Page 1 of 5
Parent/Caregiver Race: (check racial/ethnic category which best describes yourself [1] and other parent [2], if applicable) 1 2 1 2 African White/Caucasian (non-hispanic) African American (non-hispanic) Hispanic/Latino Asian or Pacific Islander Native American Indian or Alaskan Native Other (please specify): How did you learn about Spare Key? Social Worker/Medical Personnel Website/Online Friend/Family Spare Key Event Mortgage Company or other financial institution You were referred by a past recipient You are a past recipient Other (please specify): Financial & Employment Impact of Child s Medical Situation: Where do you do your personal banking (checking, savings, etc.)? Total Household Income BEFORE your child s hospitalization: $ Monthly or Annual 1 st Parent/Guardian s Employer: Full Time or Part Time Employers Address: City: State: Zip Code: 2 nd Parent/Guardian s Employer: Full Time or Part Time Employers Address: City: State: Zip Code: Has at least one parent or guardian taken or is currently taking an UNPAID leave of absence due to your child s injury/hospitalization? Yes No If yes, Start date of UNPAID leave? Total number of UNPAID work days missed by all household earners: None Less than 1 1 2-5 6-10 More than 10 *Please select the best approximate total dollar amount for each of the following categories below in relation to your child s hospitalization: Loss of income due to all time away from work due to child s illness or injury Travel-related expenses: (gas, parking, airfare, etc.) Medical expenses: (co-pays, deductibles, out-of-pocket expenses, etc.) Other additional related expenses: (childcare, meals, etc.) None $1-100 $101-500 $501-1,000 $1,001-5,000 Over $5,000 Page 2 of 5
Spare Key Mortgage Release Form This form MUST be filled out completely or the application will be DENIED. A copy of the most recent mortgage statement MUST accompany the application at the time of submission or the application will be considered incomplete and will be DENIED. Mortgage Information: Name of Mortgage Company/Lender: Monthly Payments are mailed to: Mortgage Company/Lender Telephone #: Mortgage Account #: Monthly Mortgage Payment Due: $ For verification purposes, please list the name(s) and social security #(s) of the person(s) who is/are listed on the mortgage: (Please Print) Name: Name: Social Security #: Social Security #: Are you current on your mortgage payments? Yes No *Please Note: Payments must be paid in full by the 10 th of the month when verified or the application will be denied. Are payments automatically withdrawn from your account? Yes No If yes, what day of the month are funds withdrawn from your account for payment? I/We hereby authorize the mortgage company listed above to provide my/our loan status to Spare Key. Signature Date Signature Date Note: If an application is approved and the mortgage payment exceeds the approved Spare Key mortgage grant amount, the applicant must be able to pay the difference between their mortgage payment amount and the approved Spare Key mortgage grant amount or the grant will be voided and the family will not be eligible. Page 3 of 5
Spare Key Consent Form Application Consent and Authorization: I have read and understand the Spare Key Guidelines. I attest that all information on this application is true to the best of my knowledge. I authorize Spare Key and my medical care provider to discuss my family s medical information pertinent to this case. Signature of parent/guardian: Signature of parent/guardian: Date: Date: Sharing Your Story: It is extremely important for future donors to hear directly from the Spare Key Families about the impact that the mortgage grant has made in their lives. Periodically, we look for families who are willing to share their story in order to help us raise awareness about the important service that Spare Key offers. Are you willing to share your family s story in the future? Please initial: Yes No Spare Key Survey: If approved, approximately 90 days after receiving the mortgage grant, you will be emailed an easy and brief online survey concerning the services and assistance that you received from Spare Key. The information received through this survey will be used to help secure additional funding as well as help us to better serve future families facing their child s medical crisis. Families are eligible to receive mortgage assistance from Spare Key regardless of their willingness to complete the survey. Page 4 of 5
Medical Information Form *This portion of the application must be completed ONLY by either the child s SOCIAL WORKER or MEDICAL CARE PROFESSIONAL.* Dates of child s hospitalizations: Is child currently admitted to hospital? Yes No Date of Most Recent Admission: Date of Most Recent Release : Additional Hospitalizations: Child s Primary Diagnosis: Child s current condition: Stable Critical Declining Deceased Child s social worker/medical care provider: Phone Number: Email: Hospital Name & Address: City: State: Zip Code: Please give a brief description of the child s medical condition and reason for hospitalization: I certify the medical information above and my contact information is accurate and true. Signature: Date: Page 5 of 5