APPLICATION FOR REIMBURSEMENT
Please gather the
following information to submit with this application, where applicable.
1. Federal Income Tax statement for the most
recent year.
2. Electronic government assistance transfer
card, pay stubs, or any document confirming participation in a government
assistance program including: HUD section 8 Housing subsidy, Medicaid, Food
Stamps Program, or the WIC Program.
Name
of Person Requiring Assistance:
Last First Middle
Address________________________________________________ State _______ Zip ____________
reimbursed
by other resources.
The undersigned requests
reimbursement in the amounts shown below.
If additional space is needed, please use another copy of this claim
form.
STIPEND
EXPENSES CLAIMED
Date
Incurred Name
of Provider Describe Expense Amount
_______ _______________________ _____________________________ $_______
_______ _______________________
_____________________________
$_______
_______ _______________________
_____________________________
$_______
_______ _______________________ _____________________________ $_______
Total Amount Claimed: $_______
NOTE: A written statement must be submitted by
a transplant center representative directly
to The Living Bank certifying the need for assistance under this program. You will not be able to claim this expense as
a tax deduction.
READ
CAREFULLY: The
undersigned certifies that all expenses for which reimbursement is claimed by
submission of this form were incurred during a one-year period and that the
applicant has not been reimbursed by insurance or any other organization as
outlined in the guidelines for this program which I have read and agreed to by
my signature below. The undersigned
understands that s/he is alone fully responsible for the sufficiency, accuracy
and veracity of all information relating to this claim and that unless an expense
for which payment or reimbursement is claimed is a proper expense under this
program, the undersigned may be liable for the payment of all related taxes,
including federal, state or city income tax on amounts paid from the program
which relate to such expense. The
undersigned further understands that no medical tax deduction is permitted for
amounts for which reimbursement is made.
__________________________________________________________ _______________
Claimants Signature – Print Here: Date
Claims and
documentation should be sent to: The
Living Bank, P.O. Box 77265, Houston, TX
77265-6725
Questions: Please call 713-528-2971 or e-mail: charrington@livingbank.org.