Apply For A Grant

Thank you for your interest in applying for support from the Love from Margot Foundation. We are glad you found us and we will contact you shortly after you submit your completed application along with the required supplemental documentation.

We like to keep our application simple and as seamless as possible, but we do require an initial intake meeting with each client as well as income, address, and identification verification and a doctor’s certification to approve your application with the foundation. Please use the form below to submit all your information to us.

*Please be aware that funds are limited and based on availability. Submission of an application does not guarantee support.

Please use the following link if you or someone you know cannot access our website and requires a downloadable form. Otherwise, we really prefer that you please fill out the online Grant Application below.

Click Here to Download a Love From Margot Foundation Grant Application

Step 1 of 3

Grant Application
Referring Agency
Applicant Information
Name
First Last
Phone
Best phone number to reach you.
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
MM slash DD slash YYYY
Age
Gender
- Female
- Male
Employment Status
What is your current employment status?

Income & Employment Information
Individual Income

Monthly individual gross income
Household Income

Monthly household gross income
Household Size

Family members in household
Detailed Income Breakdown
Please supply a detailed breakdown of your individual and household income
Employer

Name of your last/current employer
Date Employed
MM slash DD slash YYYY

Date of last employment
Years with Employer

Number of years with last employer
Employer Contact

Name of contact at last/current employer
Employer Phone
Phone for contact at last/current employer
Please ensure to include the following items with your application. Incomplete applications may not be considered:
1. Photo Submission
2. Income Verification (income Statement/W2)
3. Original Diagnosis AND Most Recent Diagnosis
Upload Your Photo Here*
Max. file size: 256 MB.
Upload Your Income Verification/W2 Here*
Max. file size: 256 MB.
Upload Your Original Diagnosis AND Most Recent Diagnosis Here*
Max. file size: 256 MB.
Terms and Conditions
By submitting a grant application you authorize the Love From Margot Foundation to verify your income with the employer listed above. You also authorize the above listed employer to give the Love From Margot Foundation information concerning income and earnings.

By submitting a grant application to the Love From Margot Foundation, I consent to use all of the information I provide for the purpose of promoting the Love From Margot Foundation, soliciting donation, and sharing our work and the need in this are donors and the public. I consent by submitting the grant application, regardless of whether or not the Love From Margot Foundation is able to fund my grant request. Love From Margot Foundation has the right to use my information, including my image, name, age and city and the right to use all or a portion of my story in all forms and media including advertising and related promotion through the work and in perpetuity. I waive the right to inspect or approve the use of this information. Love From Margot Foundation may edit any information I submit for length, content or clarity, in their sole discretion. I waive any and all claims of defamation, invasion of privacy, or infringement of moral rights, rights of publicity or copyright. My consent is provided on behalf of myself, my heirs, successors and assigns.

I further acknowledge that the medical information I have provided above in this application and any information I may subsequently provide to the Love From Margot Foundation upon request including a doctor’s certification, is voluntarily provided for purposes of obtaining charitable financial assistance from the Foundation. I hereby release such information to the Love From Margot Foundation and its affiliates and advisors, including in the event that the Foundation is considered a covered entity under the Health Insurance Portability and Accountability Act of 1996 (aka HIPPAA), 42 U.S.C. 130d and 45 CFR 160-164. I also authorize the release of my individually-identifiable medical information by the Love From Margot Foundation to third-parties when required by law, or to my duly-authorized agent without restriction.

I also consent to being placed onto the email marketing lists for both the Love From Margot Foundation and Mike Murphy Unfiltered and consent to receiving regularly weekly updates from both newsletters.

When you agree to the above Terms and Conditions you will be allowed to submit your Grant Application.
Terms and Conditions.*
- I have read and agreed to the Terms and Conditions.

Apply For A Grant

Step 1 of 3

Grant Application

Applicant Information

Medical Information

Additional Information

Income & Employment Information

Terms and Conditions