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Sue's Gift 2024 Application

Sue's Gift is dedicated to supporting women in Colorado with gynecologic cancer through peer support, financial assistance, and educational resources because we want you to know you are not alone.

Sue's Gift (initially known as the Sue DiNapoli Ovarian Cancer Society) was founded by the family of Sue DiNapoli following her death in 2005 to provide financial support to women in Southern Colorado with ovarian cancer. Now providing assistance for all gynecologic cancers throughout Colorado, our financial grant program helps with medical and daily living expenses during or immediately after cancer treatment.

The Woman to Woman program was founded in 2004 at Mount Sinai Medical Center in New York City. The Ovarian Cancer Research Alliance launched a national expansion of the program, and in 2018 Sue's Gift was the recipient of a community grant to establish the peer support program in Colorado. Women now have the opportunity to connect via phone, email, or text with a survivor who had the same diagnosis and a similar experience thereby reducing feelings of isolation and fear of the unknown.

Please complete the first portion of this application to request a mentor who can provide hope and encouragement following a cancer diagnosis.

Complete the entire form to request a mentor and apply for financial assistance.

Date:

(mm/dd/yyyy)

Contact Information

Name:

First Name

Last Name

Address:

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

County

Email:

Verify Email

Cell phone:

Home phone:

Date of birth:

(mm/dd/yyyy)

Race/Ethnicity:

Please list a contact person: (Name / Relationship / Phone / Email)

Who referred you to Sue's Gift? Please include a name and facility.

Work Background

If yes, how many hours per week?

What is your work experience?

How many wage earners are in the home?

How many dependents are in the home?

What is the total number of people in the home?

Medical Information

What date was your cancer diagnosed?

(mm/dd/yyyy)

What was your age at the time of diagnosis?

Date of recurrence (if applicable):

(mm/dd/yyyy)

What treatment are you receiving, have received, or expect to receive?

Surgery

Chemotherapy

Radiation therapy

PARP-inhibitor

Immunotherapy

Clinical trial

Please list the dates of treatments.

Chemotherapy / Radiation therapy / Other treatments

Provide any other medical details that you feel are relevant.

Support System

In general terms, describe your support system.

Currently, what are your greatest challenges?

Is there anything more you'd like to share about yourself?

Peer Support: If you already have a mentor, please provide her name below:

Signature:

By typing your name above, you verify the information you have submitted is accurate and complete.

Financial Assistance

Financial assistance grants will be awarded to qualified applicants in the amount of $500. Recipients may apply for a second $500 grant per rolling calendar year (meaning the second application must be dated at least 12 months from the date of the first application), if the patient is in treatment or within three months of completing treatment. There is a maximum lifetime assistance limit of two grants. Applicants must meet residency, medical, and financial qualifications. Submission of an application is not a guarantee of assistance. If any misleading or false information is submitted in writing or by phone, Sue’s Gift has the right to take steps to recover the amount awarded.

Qualifications for assistance:

Residency:

Proof of Colorado residency (Colorado driver's license, Colorado ID, or a utility or medical bill that includes the applicants name and address)
Proof of residency can be emailed to sherry@suesgift.org. If you are unable to email your document, ask your healthcare provider to email it for you.

Medical:

Diagnosis of a gynecologic cancer
Currently receiving treatment (e.g., chemotherapy, radiation therapy, surgery, PARP-inhibitor) or completed treatment for a gynecologic cancer within the last three months)
Medical Verification (Upon receipt of your application, we will obtain medical verifiction of your diagnosis from your oncologist)

Financial:

Your monthly household expenses must be more than your monthly household income (income received from patient and her domestic partner, regardless of gender).
Total household income must be less than or equal to 300% of the Federal Poverty Level.
Your available assets, including cash, investments, and real estate properties other than you home, are less than the total of six months of your household expenses during treatment.

Income

List MONTHLY household income for any of the following: (Note: We may ask you to provide a copy of your most recent Federal Income Tax Return.)

Your wages after payroll taxes (take-home pay):

Spouse or partner's wages after payroll taxes (take-home pay):

Income from self-employment or rental property:

Short or long-term employer disability insurance or unemployment insurance:

Social Security / SSI / SSDI / Retirement / Pension / IRA:

Alimony or child support:

Help from family members / friends / faith community / nonprofit organizations:

TOTAL CURRENT MONTHLY HOUSEHOLD INCOME:

Assets

Cash / Checking account:

Savings account:

Investments value:

Real estate value (other than the house you live in; e.g., a second property):

Expenses

List MONTHLY household expenses for any of the following:

Rent or mortgage:

Utility bills (gas, electric, water, internet, phone, TV):

Food:

Gasoline:

Car payment / Car insurance / Parking / Public transportation:

Child care / Child support paid:

Medical expense / Prescription costs (out of pocket) / Health insurance premiums:

Loan payments / Credit card payments:

TOTAL MONTHLY HOUSEHOLD EXPENSES:

Additional information

Have you previously received a financial assistance grant from Sue's Gift?

Yes

If you answered "yes," what year did you receive the grant?

Please share any additional information that is relevant to your application.

Signature:

By typing your name above, you verify the information you have submitted is accurate and complete.

Financial Assistance Grant / Release of Information

After receiving your application, I will be in touch by phone as well as email to send a Release of Information form that you can sign digitally granting us permission to request medical verification from your physician in order to consider your application.

I look forward to connecting with you,

Sherry Martin, LCSW
Patient Services Director