Baseball assistance team 245 Park Avenue, 31st Floor New York, ny 10167



Download 71.85 Kb.
Date09.06.2018
Size71.85 Kb.
#54010

BASEBALL ASSISTANCE TEAM


245 Park Avenue, 31st Floor

New York, NY 10167


212-931-7822

Fax: 212-949-5433

T

GRANT APPLICATION

oll Free: 866-605-4594



  1. The following is an application for a Baseball Assistance Team (B.A.T.) Grant. Please fill out this application as completely as possible. Any blank areas may hold up the decision process, as government regulations require us to have detailed information. Once you have completed the form, return it to the address above. If you have any questions, please call.



IMPORTANT: ANSWER ALL QUESTIONS


(Please print in ink)

GENERAL INFORMATION TO BE COMPLETED BY APPLICANT



Name: _______________________________________________________ E-Mail: _______________________________________


Address: ____________________________________________________________________________________________________

City: _____________________________________ State: _________________________ Zip Code: _________________________

Date of Birth: _________________________________________ Home Telephone: ( ) ________________________________

Social Security #: ______________________________________ Work Telephone: ( ) ________________________________

In case of emergency, contact: Name: _____________________________________ Telephone: ____________________________

RELEASE OF INFORMATION



IN ORDER TO HELP YOU, B.A.T MUST BE ABLE TO VERIFY ALL INFORMATION
I authorize B.A.T. or its duly authorized representatives to contact, in person and/or by phone, all persons, creditors, banks, businesses, doctors, hospitals, and consultants and/or therapists, etc. listed herein for the purpose of verifying or obtaining additional information.
I further release B.A.T. and its duly authorized representative from any and all responsibility resulting from the release of any such information.
Signed: __________________________________________________________________ Date: ____________________________

Print Name: _________________________________________________________________________________________________

MARITAL STATUS



Single  Married  Widow/Widower  Divorced 

Spouse Information:


Name: _____________________________________________________________________________________________________
Date of Birth: _________________________________________ Social Security #: ______________________________________

GRANT APPLICATION






            1. LIVING ARRANGEMENTS

Do you live alone?  Yes  No With another family ?  Yes  No

With spouse?  Yes  No With other relatives?  Yes  No

With children?  Yes  No In a retirement home?  Yes  No

Others?  Yes  No If yes, name of person ________________________
If you have children, please provide the following:
NAME BIRTHDATE SOCIAL SECURITY NUMBER
____________________________________ ________________________ ____________________________
____________________________________ ________________________ ____________________________
____________________________________ ________________________ ____________________________
____________________________________ ________________________ ____________________________
____________________________________ ________________________ ____________________________

            1. BASEBALL EXPERIENCE / RELATIONSHIP

Please list teams and years of experience that you or your spouse had in the Major, Minor or Negro Leagues.


TEAM(S) YEAR(S)
___________________________________________________________________ ____________________________
___________________________________________________________________ ____________________________
___________________________________________________________________ ____________________________
___________________________________________________________________ ____________________________
___________________________________________________________________ ____________________________
___________________________________________________________________ ____________________________

If you or your spouse did not play baseball, what is your or your spouses connection to baseball? (Umpire, Front Office, etc.)


ORGANIZATION(S) YEAR(S)
___________________________________________________________________ ____________________________
___________________________________________________________________ ____________________________
___________________________________________________________________ ____________________________
___________________________________________________________________ ____________________________

GRANT APPLICATION

INCOME

            1. SOURCES OF INCOME (HOUSEHOLD)

Per Month Per Year

A.

Social Security  Yes  No _____________________________ ___________________________

Disability  Yes  No _____________________________ ___________________________

Baseball Pension  Yes  No _____________________________ ___________________________

Other Pension  Yes  No _____________________________ ___________________________

Veteran’s Benefits  Yes  No _____________________________ ___________________________

Other Sources **  Yes  No _____________________________ ___________________________

Employment  Yes  No _____________________________ ___________________________


TOTAL (also record on page 6) _____________________________ ___________________________
** Interest Income from Mutual Funds (i.e. Vanguard Funds, Fidelity Funds, etc.) Stocks, Life Insurance Policies, Annuities, etc. or Major League Baseball Players Association Licensing Money
B.

Employment
Are you employed?  Yes  No
Employer’s Full Address and Phone Number: _______________________________________________________________

_______________________________________________________________

_______________________________________________________________

( ) __________________________


If you are unemployed: Are you able to work?  Yes  No

If you are unable to work, please list reasons:

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________
C.

Assets
Checking Account(s)
Bank: ________________________________________________________________________________

Bank Address: ________________________________________________________________________________

Phone Number: ( ) _________________________________________________________________________

Bank Account Number: ________________________________________________________________________________

Current Balance: ________________________________________________________________________________
Savings Account(s)
Bank: ________________________________________________________________________________

Bank Address: ________________________________________________________________________________

Phone Number: ( ) _________________________________________________________________________

Bank Account Number: ________________________________________________________________________________

Current Balance: ________________________________________________________________________________

GRANT APPLICATION


D.

Other Assets
List all assets and their values if over $1,000 (i.e. money market, mutual funds, stock, permanent life insurance, autos, etc.). (If automobile(s), list make, year and estimated value).
ASSETS VALUE
_________________________________________________________________ ____________________________

_________________________________________________________________ ____________________________

_________________________________________________________________ ____________________________

_________________________________________________________________ ____________________________

_________________________________________________________________ ____________________________

_________________________________________________________________ ____________________________

_________________________________________________________________ ____________________________

_________________________________________________________________ ____________________________

_________________________________________________________________ ____________________________

            1. OTHER ASSISTANCE

Are you receiving any public or private assistance?


If yes, please explain the nature of the assistance: _____________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________ ____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________
Who can we contact regarding the assistance you are receiving? ________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________



GRANT APPLICATION

EXPENSES
            1. DWELLING EXPENSES


Mortgage: Is help needed with the mortgage?  Yes  No
If the answer is yes: What is the total amount of your mortgage? ____________________________

What is the value of your home? ____________________________

What is your monthly mortgage payment? ____________________________

Date of expected mortgage completion? ____________________________

Are you current with your payments?  Yes  No

Number of years at current address? ­­­­­­­­­­­­­­­­­____________________________


If the answer is no: How many months are you behind with payments? ____________________________

Total amount needed to bring you current ____________________________


Please list the name and address of mortgage holder:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Telephone Number: ( ) ______________________________________________________________________________




Rent: Is help needed with the rent?  Yes  No

If the answer is yes: What is the total amount of your monthly rent? ____________________________

Are you current with your payments? ____________________________

Number of years at current address? ____________________________

If the answer is no: How far are you behind with your payments? ____________________________

Total amount needed to bring you current? ____________________________

Please list the name and address of landlord:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Telephone Number: ( ) ______________________________________________________________________________


GRANT APPLICATION


            1. HOUSEHOLD EXPENSES


MONTHLY EXPENSES
Food $____________________ Health Insurance $____________________

Clothing $____________________ Life Insurance $____________________

Transportation $____________________ Homeowners Insurance $____________________

Household Supplies $____________________ Auto Insurance $____________________

Maintenance Fees $____________________ Auto (Loan or Lease) $____________________

Mortgage/Rent $____________________ Child Care / Alimony $____________________

Cable / Dish $____________________ Prescriptions $____________________
Total Owed Average Monthly Bill Months Owed

Electricity ______________________ ________________________ ____________________________

Gas ______________________ ________________________ ____________________________

Water ______________________ ________________________ ____________________________

House Telephone ______________________ ________________________ ____________________________

Cell Phone ______________________ ________________________ ____________________________


TOTAL MONTHLY EXPENSES $________________________________

TOTAL MONTHLY INCOME $__________________________________

(From Total on Page 3)
UTILITIES

Is help needed with the utilities?  Yes  No

If the answer is yes:

Are you current with your payments?  Yes  No

If the answer is no, what is the total amount to bring you current? $______________________
PLEASE LIST ALL CREDITORS, INCLUDING AUTOS:

Name Address Amount Account Number

____________________ __________________________ _________________ _________________

____________________ __________________________ _________________ _________________

____________________ __________________________ _________________ _________________

____________________ __________________________ _________________ _________________

____________________ __________________________ _________________ _________________



NOTE: These expenses must be documented with copies or the actual bills when requested.
DO NOT SEND BILLS AT THIS TIME.

GRANT APPLICATION

            1. MEDICAL

Is help needed for your medical needs?  Yes  No


If the answer is yes, describe your medical needs or disabilities: _________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Are you covered by : Medical Insurance  Yes  No Dental Insurance  Yes  No

Medicare  Yes  No Medicaid  Yes  No

Other ______________  Yes  No


            1. HOSPITAL

Is help needed with a hospital?  Yes  No


If the answer is yes, what is the total of your bill? _____________________________________________________
Are you current with your payments?  Yes  No

If the answer is no, how many months are you behind with your payments? ________________________________

What is the amount needed to bring you current?______________________________________________________

(If answer is yes, and help is needed, you must fill out the enclosed medical expense form).



            1. DOCTORS

Is help needed with doctors?  Yes  No


If answer is yes, what is the total of your bill? ________________________________________________________
Are you current with your payments?  Yes  No
If answer is no, how many months are you behind with your payments? ___________________________________

What is the amount needed to bring you current? _____________________________________________________

(If answer is yes, and help is needed, you must fill out the enclosed medical expense form).
If there is a need for continuing doctor’s care, please list the reasons.

____________________________________________________________________________________________________

____________________________________________________________________________________________________


GRANT APPLICATION

Should you feel a need to add more information, please feel free to use this space. We would appreciate any additional information you would like to provide us.


________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
BASEBALL ASSISTANCE TEAM

245 Park Avenue


34th Floor

New York, NY 10167

(212) 931-7821/7822


MEDICAL EXPENSE FORM


Name: ______________________________________________________________________________________________


Address: _____________________________________________________________________________________________
City: ________________________________________________ State: ___________________ Zip: __________________
Home Telephone: ( ) ________________________________ Work Telephone: ( ) __________________________

If I am not available, please contact:


Name: _______________________________________________ Telephone: ( ) _______________________________


DATE

MEDICAL BILLS (Doctor/Hospital/Prescriptions)

* DO NOT SEND BILLS AT THIS TIME *


AMOUNT



































































































Page of


Download 71.85 Kb.

Share with your friends:




The database is protected by copyright ©ininet.org 2024
send message

    Main page