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Cancer Support
Cancer Support Group
Living Waters Assistance Program Application
Resources
MASS Events
Register for MASS Presentation
Register for Mammogram Only
Request to Host a MASS Presentation
Blog Articles
About Us
Donate
via Zelle
via PayPal
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Living Waters Breast Cancer Assistance Program Application
Complete Entirely
Complete Entirely
PERSONAL INFORMATION
Select how you heard about this financial assistance program
FL Dept of Health
Google Search
Facebook
Flyer
Family/Friend
Other
Select a county
Alachua
Baker
Bay
Bradford
Brevard
Broward
Calhoun
Charlotte
Citrus
Clay
Collier
Columbia
De Soto
Dixie
Duval
Escambia
Flagler
Franklin
Gadsden
Gilchrist
Glades
Gulf
Hamilton
Hardee
Hendry
Hernando
Highlands
Hillsborough
Holmes
Indian River
Jackson
Jefferson
Lafayette
Lake
Lee
Leon
Levy
Liberty
Madison
Manatee
Marion
Martin
Miami-Dade
Monroe
Nassau
Okaloosa
Okeechobee
Orange
Osceola
Palm Beach
Pasco
Pinellas
Polk
Putnam
Saint Johns
Saint Lucie
Santa Rosa
Sarasota
Seminole
Sumter
Suwannee
Taylor
Union
Volusia
Wakulla
Walton
Washington
WHAT IS YOUR RACE? (check all that apply)
Black or African American
White or Caucasian
Asian
American Indian or Alaska Native
Middle Eastern or North African (MENA)
Native Hawaiian or Pacific Islander
Prefer Not to Answer
NUMBER OF PEOPLE IN YOUR HOUSEHOLD
1
2
3
4
5
6
7
8
9
LIST HOUSEHOLD MEMBERS
Household Member #1
Household Member #2
Household Member #3
Household Member #4
EMERGENCY CONTACT
HOUSEHOLD INCOME
Select a household income
$0 – $25,000
25,001 – $50,000
50,001 – $100,000
PHYSICIAN NOTE OF TREATMENT AND DIAGNOSES
ARE YOU IN ACTIVE TREATMENT?
Active treatment is defined as the period after a positive diagnosis of breast cancer has been made (with a diagnostic biopsy), and during which therapies are being administered, including surgical procedures to remove the cancer (e.g., single, or bi-lateral mastectomy, lumpectomy, axillary dissection, or sentinel node biopsy), chemotherapy or radiation. Active treatment does not include reconstruction surgeries or long-term hormonal therapies.
Yes
No
Is long term hormonal therapy your only treatment?
Yes
No
Has your household working income decreased?
Yes
No
Did your spouse partner experience a loss of income due to your breast cancer diagnosis?
Yes
No
Do you meet the household income of 200% or less of the federal poverty level based on last year’s federal tax return?
Yes
No
KIND OF ASSISTANCE NEEDED
Rental/Mortgage Assistance
Utilities Assistance
Food/Personal Items
Applications are reviewed 48-72 hours after they are received. Additional information will be required for application approval. Please note this application is for one (1) time assistance for those currently undergoing breast cancer treatments. Applications are approved based on availability of funds.
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