Financial Assistance
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Endowment Funds Application
HARRIET B. CULLEN GRANT APPLICATION
Print this page, complete, and submit application with copy of previous year. Income Tax Return to:
Upstate New York Transplant Services, Inc.
110 Broadway
Buffalo, NY 14203
or fax to 716-348-5432
If you have any questions about the application process, please call 716-853-6667.
Name: __________________________________________
Phone: __________________________
Address: _______________________________________
Employer: ______________________________________
Address: _______________________________________
Gross Income: ________________________
Social Security #: ____________
Did you file a state and/or federal income tax return in the past 12 months? ______
If yes, attach copy.
Date of Birth: _____________________
Married: ___________ Single ___________
Number and Age of Dependents: __________________
Health Insurance: _______________________________
Medicare: ___________________________
Medicaid: _____________________
Condition Requiring Treatment (must relate to eye sight):
_________________________________________________
Charge Code(s)(Obtained from Provider of Service):
___________________
Nature of Treatment Needed:
__________________________________________________
Provider of Service Requiring Payment:
______________________________________________
Phone # _______________
Address of Provider:
_________________________________________________
If application is being made by someone other than above applicant, please provide:
Name: _____________________________________
Relationship: ____________
Phone Number: ______________________________
I certify that the above information is true to the best of my knowledge.
I agree to any investigation made by Upstate New York Transplant Services, Inc., to verify or confirm the information in connection with my request for aid from the Harriet B. Cullen Fund.
Signature: _________________________________
Date: ________________________________