Common use of Statement of Need Clause in Contracts

Statement of Need. Please describe any needs, challenges and obstacles that you face and what it would it would mean to you to receive breast reconstruction assistance from the AiRS Foundation. I understand AiRS Foundation may verify the financial information contained in this Grant Application (“Application”) in connection with AiRS Foundation’s evaluation of this Application, and by my signature hereby authorize my employer or any individual listed on this Application to certify or provide additional details with respect to the information provided in this Application. I also authorize AiRS Foundation to request reports from credit reporting agencies and the Social Security Administration. I certify that the statements made in this Application are true and correct, to the best of my knowledge and belief, and are made in good faith. I am aware that falsification or misrepresentation of information on this Application may result in denial of my grant request. Signature of Applicant Printed Name Date Please email or mail your signed AiRS Client Agreement, AiRS Grant Application Form, your Statement of Need, and the AiRS Foundation News & Publication Authorization Form to: Email: xxxx@xxxxxxxxxxxxxx.xxx NEWS & PUBLICATION AUTHORIZATION FORM Allowing AiRS to share your story in our marketing materials helps personalize our cause, raise money and promote awareness for our mission. If you are selected to receive a grant for breast reconstruction surgery, by signing below, you understand and authorize AiRS to medical condition and to use interview you and/or your physician about your name, age, basic description, and image (a photograph and/or video) for fundraising and promotional purposes including but not limited to advertising/marketing, print, internet, video, broadcast and television. You also agree to be available from time to time to be interviewed by members of the media via email, telephone or in person (where possible). Unless otherwise revoked, I understand that this authorization will expire 50 years from the date of signature. I understand that I may revoke this authorization at any time, except to the extent that the AiRS Foundation sending a written statement of revocation that specifically refers to the authorizations. I hereby release the AiRS Foundation and it’s board of directors, officers, agents and employees from any and all liability connected with the capture, use or release of this Media information. By signing this authorization I acknowledge that I have read and understand the statements contained herein. I understand that the AiRS Foundation will provide me with a copy of this signed authorization form. Signature Date Printed Name Sincerely, THE AiRS TEAM ALLIANCE IN RECONSTRUCTIVE SURGERY (AiRS) FOUNDATION POLICY FOR GRANTS TO INDIVIDUALS All grant applications for medical expenses relating to breast reconstructive surgery submitted through this process will be considered. Each applicant who has undergone a mastectomy will be considered for a grant, based on their application details and the received support information. All grants are awarded through an objective and nondiscriminatory selection process. Criteria for AiRS Foundation’s grants to individuals are based on the foundations submission to the IRS at the time of its approval for 501c3 standing as a charitable foundation. Xxxxxx awarded may range from an individual’s medical bill co-pay to the full cost of reconstructive surgery, hospitalization, and other related medical expenses. An individual may be disqualified based on IRS Code Section 4958 or a grant may be revoked if it is determined that information has been falsified. For AiRS Grant Policy Definitions, see additional information on this pull-down menu and feel free to contact us

Statement of Need. Must be typed or printed legibly. Please describe any needs, challenges and obstacles that you face and what it would it would mean to you to receive breast reconstruction assistance from the AiRS Foundation. If your income exceeds 100% Federal Poverty Guidelines, you must document financial hardship, including monthly budget with detailed expenses, to be considered. I understand AiRS Foundation may verify the financial information contained in this Grant Application (“Application”) in connection with AiRS Foundation’s evaluation of this Application, and by my signature hereby authorize my employer or any individual listed on this Application to certify or provide additional details with respect to the information provided in this Application. I also authorize AiRS Foundation to request reports from credit reporting agencies and the Social Security Administration. I certify that the statements made in this Application are true and correct, to the best of my knowledge and belief, and are made in good faith. I am aware that falsification or misrepresentation of information on this Application may result in denial of my grant request. Signature of Applicant Printed Name Date Please email or mail your signed AiRS Client Agreement, AiRS Grant Application Form, your Statement of Need, and the AiRS Foundation News & Publication Authorization Form to: Email: xxxx@xxxxxxxxxxxxxx.xxx NEWS & PUBLICATION AUTHORIZATION FORM Allowing AiRS to share your story in our marketing materials helps personalize our cause, raise money and promote awareness for our mission. If you are selected to receive a grant for breast reconstruction surgery, by signing below, you understand and authorize AiRS to medical condition and to use interview you and/or your physician about your name, age, basic description, and image (a photograph and/or video) for fundraising and promotional purposes including but not limited to advertising/marketing, print, internet, video, broadcast and television. You also agree to be available from time to time to be interviewed by members of the media via email, telephone or in person (where possible). Unless otherwise revoked, I understand that this authorization will expire 50 years from the date of signature. I understand that I may revoke this authorization at any time, except to the extent that the AiRS Foundation sending a written statement of revocation that specifically refers to the authorizations. I hereby release the AiRS Foundation and it’s board of directors, officers, agents and employees from any and all liability connected with the capture, use or release of this Media information. By signing this authorization I acknowledge that I have read and understand the statements contained herein. I understand that the AiRS Foundation will provide me with a copy of this signed authorization form. Signature Date Printed Name Sincerely, THE AiRS TEAM ALLIANCE IN RECONSTRUCTIVE SURGERY (AiRS) FOUNDATION POLICY FOR GRANTS TO INDIVIDUALS All grant applications for medical expenses relating to breast reconstructive surgery submitted through this process will be considered. Each applicant who has undergone a mastectomy will be considered for a grant, based on their application details and the received support information. All grants are awarded through an objective and nondiscriminatory selection process. Criteria for AiRS Foundation’s grants to individuals are based on the foundations submission to the IRS at the time of its approval for 501c3 standing as a charitable foundation. Xxxxxx awarded may range from an individual’s medical bill co-pay to the full cost of reconstructive surgery, hospitalization, and other related medical expenses. An individual may be disqualified based on IRS Code Section 4958 or a grant may be revoked if it is determined that information has been falsified. For AiRS Grant Policy Definitions, see additional information on this pull-down menu and feel free to contact usus at xxxx@XxXXxxxxxxxxxx.xxx with any questions or comments.

Statement of Need. Must be typed or printed legibly. Please describe any needs, challenges and obstacles that you face and what it would it would mean to you to receive breast reconstruction assistance from the AiRS Foundation. If your income exceeds 100% Federal Poverty Guidelines, you must document financial hardship, including monthly budget with detailed expenses, to be considered. I understand AiRS Foundation may verify the financial information contained in this Grant Application (“Application”) in connection with AiRS Foundation’s evaluation of this Application, and by my signature hereby authorize my employer or any individual listed on this Application to certify or provide additional details with respect to the information provided in this Application. I also authorize AiRS Foundation to request reports from credit reporting agencies and the Social Security Administration. I certify that the statements made in this Application are true and correct, to the best of my knowledge and belief, and are made in good faith. I am aware that falsification or misrepresentation of information on this Application may result in denial of my grant request. Signature of Applicant Printed Name Date Please email or mail your signed AiRS Client Agreementsigned, AiRS Grant Application Form, your Statement of Need, and the AiRS Foundation News & Publication Authorization Form to: Email: xxxx@xxxxxxxxxxxxxx.xxx Mailing Address: AiRS Foundation, 0000 Xxx Xxxx., Ste. 1504, Dallas, TX 75219 4828-1316-2374.2/15556/1301/012219 NEWS & PUBLICATION AUTHORIZATION FORM Allowing AiRS to share your story in our marketing materials helps personalize our cause, raise money and promote awareness for our mission. If you are selected to receive a grant for breast reconstruction surgery, by signing below, you understand and authorize AiRS to medical condition and to use interview you and/or your physician about your name, age, basic description, and image (a photograph and/or video) for fundraising and promotional purposes including but not limited to advertising/marketing, print, internet, video, broadcast and television. You also agree to be available from time to time to be interviewed by members of the media via email, telephone or in person (where possible). Unless otherwise revoked, I understand that this authorization will expire 50 years from the date of signature. I understand that I may revoke this authorization at any time, except to the extent that the AiRS Foundation sending a written statement of revocation that specifically refers to the authorizations. I hereby release the AiRS Foundation and it’s board of directors, officers, agents and employees from any and all liability connected with the capture, use or release of this Media information. By signing this authorization I acknowledge that I have read and understand the statements contained herein. I understand that the AiRS Foundation will provide me with a copy of this signed authorization form. Signature Date Printed Name Sincerely, THE AiRS TEAM Please email or mail your signed, AiRS Grant Application Form to: Email: xxxx@xxxxxxxxxxxxxx.xxx Mailing Address: AiRS Foundation, 0000 Xxx Xxxx., Ste. 1504, Dallas, TX 75219 4828-1316-2374.2/15556/1301/012219 ALLIANCE IN RECONSTRUCTIVE SURGERY (AiRS) FOUNDATION POLICY FOR GRANTS TO INDIVIDUALS All grant applications for medical expenses relating to breast reconstructive surgery submitted through this process will be considered. Each applicant who has undergone a mastectomy will be considered for a grant, based on their application details and the received support information. All grants are awarded through an objective and nondiscriminatory selection process. Criteria for AiRS Foundation’s grants to individuals are based on the foundations submission to the IRS at the time of its approval for 501c3 standing as a charitable foundation. Xxxxxx awarded may range from an individual’s medical bill co-pay to the full cost of reconstructive surgery, hospitalization, and other related medical expenses. An individual may be disqualified based on IRS Code Section 4958 or a grant may be revoked if it is determined that information has been falsified. For AiRS Grant Policy Definitions, see additional information on this pull-down menu and feel free to contact usus at xxxx@XxXXxxxxxxxxxx.xxx with any questions or comments. Please email or mail your signed AiRS Grant Application Forms to: Email: xxxx@xxxxxxxxxxxxxx.xxx Mailing Address: AiRS Foundation, 0000 Xxx Xxxx., Ste. 1504, Dallas, TX 75219

Statement of Need. Must be typed or printed legibly. Please describe any needs, challenges and obstacles that you face and what it would it would mean to you to receive breast reconstruction assistance from the AiRS Foundation. If your income exceeds 100% Federal Poverty Guidelines, you must document financial hardship, including monthly budget with detailed expenses, to be considered. I understand AiRS Foundation may verify the financial information contained in this Grant Application (“Application”) in connection with AiRS Foundation’s evaluation of this Application, and by my signature hereby authorize my employer or any individual listed on this Application to certify or provide additional details with respect to the information provided in this Application. I also authorize AiRS Foundation to request reports from credit reporting agencies and the Social Security Administration. I certify that the statements made in this Application are true and correct, to the best of my knowledge and belief, and are made in good faith. I am aware that falsification or misrepresentation of information on this Application may result in denial of my grant request. Signature of Applicant Printed Name Date Please email or mail your signed AiRS Client Agreement, AiRS Grant Application Form, your Statement of Need, and the AiRS Foundation News & Publication Authorization Form to: Email: xxxx@xxxxxxxxxxxxxx.xxx NEWS & PUBLICATION AUTHORIZATION FORM Allowing AiRS to share your story in our marketing materials helps personalize our cause, raise money and promote awareness for our mission. If you are selected to receive a grant for breast reconstruction surgery, by signing below, you understand and authorize AiRS to medical condition and to use interview you and/or your physician about your name, age, basic description, and image (a photograph and/or video) for fundraising and promotional purposes including but not limited to advertising/marketing, print, internet, video, broadcast and television. You also agree to be available from time to time to be interviewed by members of the media via email, telephone or in person (where possible). Unless otherwise revoked, I understand that this authorization will expire 50 years from the date of signature. I understand that I may revoke this authorization at any time, except to the extent that the AiRS Foundation sending a written statement of revocation that specifically refers to the authorizations. I hereby release the AiRS Foundation and it’s board of directors, officers, agents and employees from any and all liability connected with the capture, use or release of this Media information. By signing this authorization I acknowledge that I have read and understand the statements contained herein. I understand that the AiRS Foundation will provide me with a copy of this signed authorization form. Signature Date Printed Name Sincerely, THE AiRS TEAM ALLIANCE IN RECONSTRUCTIVE SURGERY (AiRS) FOUNDATION POLICY FOR GRANTS TO INDIVIDUALS All grant applications for medical expenses relating to breast reconstructive surgery submitted through this process will be considered. Each applicant who has undergone a mastectomy will be considered for a grant, based on their application details and the received support information. All grants are awarded through an objective and nondiscriminatory selection process. Criteria for AiRS Foundation’s grants to individuals are based on the foundations submission to the IRS at the time of its approval for 501c3 standing as a charitable foundation. Xxxxxx awarded may range from an individual’s medical bill co-pay to the full cost of reconstructive surgery, hospitalization, and other related medical expenses. An individual may be disqualified based on IRS Code Section 4958 or a grant may be revoked if it is determined that information has been falsified. For AiRS Grant Policy Definitions, see additional information on this pull-down menu and feel free to contact usus at xxxx@XxXXxxxxxxxxxx.xxx with any questions or comments.