Hunter's Wish Gift

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Page 1

Hunter's Wish Gift helps families in the United States who face extreme financial stress attributed to the costs associated with caring for a child with a Leukodystrophy. Requests are granted on a case-by-case basis and are limited to meeting needs that will enable an affected family to provide the best possible care for their child. (e.g. wheelchair lift, wheelchair accessible van, service dog, etc.

Recipient of Gift

Please enter information about the affected individual who would be the recipient of the gift.

First Name of Recipient

Last Name of Recipient

Please upload at lease one photo of the Recipient.

Please upload at lease one family photo.

Does Recipient have a Leukodystrophy?

YesNo

Please upload a letter from the affected individual's doctor which states the diagnosis.

Please explain diagnosis, prognosis and symptom management.

Which Leukodystrophy?

If Other or Unspecified, please explain.

Date of Birth

Age

Page 2

Your Request

What are you requesting?

What is the estimated cost of this request?

Please explain why the affected individual needs this gift.

If you know of a website (e.g. Amazon) where the item can be purchased, please provide the link to the time.

Please upload a photo of your requested gift if you have one.

Page 3

Your Information

The person filling out this form must be the parent or legal guardian of affected individual.

Edit this text

MotherFatherLegal Guardian

If you selected Legal Guardian, please explain.

First Name

Last Name

Mobile Phone

Mailing Street

Mailing City

Mailing State

Mailing Zip Code

Mailing Country

Living in Your Home

Number of Adults (18 years and older) living in your home.

Number of children living in your home.

Page 4

Financial Information

* If you do not provide a complete accounting of your income and expenses, your application will be denied.

Income

Select the year of your most recent Federal Tax Return.

20232022I do not file a Federal Tax Return

Please explain why you did not file a Federal Tax Return.

Total Annual Income from Line 9 of your most recent Federal Tax Return of All Adults (18 years and older) living in your home.

Please upload a copy of the first page of your most recent Federal Tax Return. Please black out your social security number.

Please upload a copy of the document that shows your annual income. Please black out your social security number.

Total Annual Income from All Adults (18 years and older) living in your home.

If your family has any other income, please enter it here. (annual income)

Total Annual Income of All Adults (18 years and older) living in your home.

Bank Accounts

Checking - Enter the total amount of funds in your Checking Accounts.

Savings - Enter the total amount of funds in your Savings Accounts.

Investment - Enter the total amount of funds in your Investment Accounts.

Total

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Expenses

Home Mortgage/Rent (per month)

Total Utilities (Electric, Gas, Water, etc.) (per month)

Total Services (Internet, TV, Phone, etc.) (per month)

Total Transportation (Car Loans, Maintenance, etc.) (per month)

Total Insurance (Homeowners, Car, etc.) (per month)

Total Health Insurance (Health, Dental, etc.) (per month)

Total Medical Not Paid by Insurance (per month)

Total of Other Expenses (per month)

Total Expenses

For all Other Expenses in Total above, please provide Name, Description, Amount of each expense per month.

Page 6

Do you agree that the information you provided on this form is complete and accurate to the best of your knowledge? If you have not provided a complete accounting of your income and expenses, your application will be denied.

YesNo

Do you agree to send photos of the recipient benefiting from the gift? These photos will be used to promote the Wish Gift program so that others may benefit too.

YesNo

Please enter your full name as confirmation of the above statement.

When you are finished, please click on the Submit button below.

Thank you!

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