10th Player Foundation

Financial Assistance Form

The 10th Player Foundation is thrilled to be able to provide gifts of financial assistance to those in need. If approved, please note the gift is non-taxable to you, the recipient, but we are required to disclose the information on your W-4 when completing the charity’s taxes at the end of the year. This is required by Federal Law and is used for tax reporting purposes only.

Please complete the W-4 form in its entirety and include a scanned copy with your application.

Thank you so much for your assistance in this matter and again, we are thankful we are able to provide financial support to those in need.

*Please note that once we receive your application it will go through our verification process. This process will take some time and we thank you for your patience. We will contact you if approved for financial assistance.

With Hope,
10th Player Foundation

Financial Assistance Application

  • I do hereby authorize all hospitals, financial institutions, and insurance groups to release to the 10th Player Foundation ("10th Player"), or its duly authorized representative, any information deemed necessary to complete its investigation of my application for financial assistance. I further authorize the 10th Player and its representative to provide such information to those institutions as may be reasonably required to assist our family and child. All consents given herein shall continue until such time as the undersigned provides notice of termination in writing. Financial assistance will be provided with the use of said funds to be specified by 10th Player. The "undersigned" means the parents or guardians of the child. The undersigned acknowledge(s) and agree(s) to: * Return any unused funds, if requested, within thirty (30) days to the 10th Player so that those funds can be utilized by the organization to benefit other families. The will 10th Player pursue restitution for grants if it is determined that the information submitted on the application is false. * Maintain records that will be made available to the 10th Player upon reasonable request, detailing the expenditures made from the funds provided by the organization. * Hold harmless and release and forever discharge the 10th Player from all claims, demands, liability and causes of action which the undersigned, heirs, representatives, executors, administrators, or any other persons acting on the undersigned’s behalf or on behalf of the undersigned’s estate have or may have by reason of this authorization. * Give continuing consent to 10th Player to use images of any and all kinds of my child, myself, and our names, so long as they are only used on behalf of 10th Player. I may void consent by checking the boxes below this provision and initialing it. Furthermore, while 10th Player will make all efforts to ensure the information provided below is handled confidentially and information will only be shared as deemed necessary to complete its investigation of my application for financial assistance, 10th Player cannot guarantee your information will be confidential and it may be possible that others will know what you have reported. I have read the guidelines for financial assistance and the eligibility checklist, and I declare that the information furnished on this application form, including attached sheets, is true and correct to the best of my knowledge. As the undersigned, I have read this release before signing below and I fully understand the contents, meaning, and impact of this release.
  • *We can only speak to the parent(s)/guardian(s) that have signed this application.
  • *Anti-Discrimination Policy: You and your child will not be discriminated against or denied assistance because of your race, religion, color, national origin, gender or political affiliation. All financial applications will be reviewed on a case-by-case basis and final determination will be made based upon your eligibility, 10th Player guidelines and the availability of funds.
 

Verification