Application for Prosthetic

Purchasing Assistance

* Currently USA Only *

Balanced Frameworx, a non-profit dedicated to amputee care, offers hope and financial aid to those in need. However, the availability of this assistance depends on our fundraising efforts, and all decisions are made at our discretion. Awards may vary based on income, assets, insurance coverage, and a sliding scale approach.

First Name *

Last Name *

Date of Birth *

Parent or Guardian if Patient is a Minor

Mobile Phone *

Email *

Address *

City *

State *

Postal code *

Are you disabled to any degree? *

Yes

Are you currently employed? *

Yes

Do you have Insurance that will be helping for this request? *

Yes

If "other" please explain

_________________________________________________________

ORTHOTIST AND PROSTHETIST INFORMATION

(If working with a facility please fill out below)

Orthotist and Prosthetist Name

Date needing help by.

Orthotist Prosthetist Phone Number

Orthotist Prosthetist Email Address

Orthotist Prosthetist Address

Street Address
City
State/Province
Postal/Zip Code

_________________________________________________________

INCOME RELATED QUESTIONS:

If "Other" please explain

_________________________________________________________

GENERAL EXPENSES:

Do you know the approximate amount you will be requesting help for? (If so, enter value in next field) *

Yes

I have no idea at this point

Approximate Financial Need (if known)

Monthly Expenses

Rent / Mortgage
Property Tax (if own home)
Homeowner's Insurance
Utilities Combined (Water, Gas Electric)
Phone
Internet - Cable - Media Subscriptions (ie Netflix, Hulu, etc)
Child Support
Credit Cards
Health Insurance Premiums
Medical / Dental
Car Insurance
Car Payments
Liens
Loans
Garnishments
Misc
Other
TOTAL monthly

_________________________________________________________

This is the first part of being eligible for assistance. If considered for assistance, applicants must cooperate fully and provide timely information for the application process. This includes ensuring all information is accurate, completing the application in its entirety, and gathering necessary documentation. The following documents are examples we may require in order to finalize your eligibility.

Previous year's W-2 forms and tax records
Bank statements (checking and savings) for the past three months
Recent paystubs for all employed family members
Proof of income from the following that apply
- Social Security
- worker's compensation
- pensions
- disability
- child support
- alimony
- unemployment benefits

As we move forward any missing documents will require a written explanation.

Our application requires a comprehensive overview of your family's financial situation, including income, assets, liabilities, and family size. The information and documents you provide are essential for determining your eligibility for assistance. Participation in this program is voluntary on both sides. This information is not intended to create a contractual right to benefits.

Note: Missing information or explanations may delay processing and could lead to denial. We strive for prompt application review and will notify you of the outcome by letter.

ACKNOWLEDGMENT & SIGNATURE

I confirmed that all information I entered here is accurate and true.
I allow Balanced Frameworx to capture my sensitive data like personal id, government id, social security number (SSN), and other information.
I have read the terms and conditions and privacy policy of Balanced Frameworx.
I understand that filling out this application does not guarantee charitable/financial assistance for my request for help.
By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in collecting your information for the purpose of considering your request for charitable assistance in acquiring or reqairing a prosthetic limb.

Date Signed *

Sign Here *

Clear

I agree to terms and conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.