Compassion - a little goes a long way

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Ommana Foundation
Application for Assistance

What Do I Need To Do To Get Assistance?

Follow these steps to apply for assistance.

Step 1. Fill out this application.
Answer as many questions as you can. If you need help applying for assistance, you may have a friend, relative or someone else help you apply. Please print the completed document, sign and email to"..

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Read The Following Information
I declare that the information on this application is correct. This includes information about identity, citizenship and alien status of the household members applying for assistance.

I understand that all information given on this application may be verified. I agree to provide documentary evidence when asked for by the Foundation. I understand that if any of the information is incorrect, that I might be subject to criminal prosecution for knowingly providing incorrect information.

Authorization To Release Information
I/We authorize any person having custody or knowledge of the information relating to me or other household members to disclose any requested information, including confidential information other than protected health information, to any authorized agent of the Ommana Foundation. This authorization will remain valid until canceled in writing or until 3 year from the date of this application. A copy of this authorization is as valid as the original.

Sign and Date the Application Here