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Beneficiary Information

Name*

Beneficiary's Date of Birth*

Email*

Cell phone or land line?*

Cell Phone

Land Line

Beneficiary's Phone Number*

Address*

Additional Information

Is English your first or second language?*

First Language

Second Language

What language do you prefer?*

English

Spanish

Other

Are you a resident of the sate of Texas?*

Yes

Do you have access to any virtual meeting platforms or Apple Face Time?*

Yes

What is the best time of day to contact you by phone?*

Do you have health insurance covering services you need financial help with?*

Yes

Name of Insurance Company

Policy Number

Group Number

Are you eligible for COBRA?*

Yes

Do you have Medicaid benefits?*

Yes

Do you have Disability Assistance (DA) benefits?*

Yes

Please provide your ongoing care doctor’s address for the office

Street Address City State ZIP Code

Please provide your ongoing care doctor’s phone number for the office

Please provide a detailed description of your medical condition, and the financial assistance you need help with, the more description you give the better we understand how we can help.

Has the applicant been diagnosed with some form of cancer?*

Yes

Beneficiary Release Agreement

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This Agreement is between Mankind, Inc. (“MKI”) a Texas non-profit corporation and

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(“BENEFICIARY”) an individual residing at

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(“ADDRESS”), effective as of

This Agreement is between Mankind, Inc. (“MKI”) a Texas non-profit corporation and NAME, (“BENEFICIARY”) an individual residing at ADDRESS, effective as of 11/21/2024.

Whereas;

MKI was established for the purpose of charitable endeavors related to men’s health; and

MKI has identified BENEFICIARY whom is suffering economic hardship; and

BENEFICIARY has made the assertion he is in need of medical care he cannot afford, and has considerable medical related debts, as of the effective date; and

Now, therefore, it is agreed by and between MKI and BENEFICIARY as follows:

The MKI board of directors will consider the needs of BENEFICIARY, and availability of funds and if possible and approved, deliver a payment or other support to BENEFICIARY by US Mail to the ADDRESS.
BENEFICIARY will apply the whole amount to his medical debt, medical bills, and future medical care costs, or costs of living related to the needed medical care, and use these funds for no other purpose.
BENEFICIARY agrees to release and hold harmless MKI and its representatives harmless from any claim, damage or responsibility, or for any outcome which may result from this transaction.
BENEFICIARY shall represent MKI in a positive light to all other parties and will not disparage its reputation or that of its board members. BENEFICIARY further consents that his name, his likeness, and the details of his medical condition and his family history and his hardship and this charitable act may be used by MRI for the purpose of its own publicity and furthering its own cause in any way MKI sees fit including digital marketing on the public internet.

MANKIND, INC. (“MKI”)

Printed: Jason W. Taylor

Signature:

Title: Co-Founder, Vice President

Date: 11/21/2024

Check*

By checking this box, I affirm to the best of my knowledge and belief that the facts represented on this application are true.

Name of Person Completing Application for Benefits*

Beneficiary’s T-Shirt Size*

How did you hear about Mankind?

Apply for Benefits

ManKind Financial Benefit Application - a Texas 501(c)3 Corporation for the benefit of Men’s Health Crisis Victims, their Families, and Awareness.

Beneficiary Information

Additional Information

Beneficiary Release Agreement

MANKIND, INC. (“MKI”)

Printed: Jason W. Taylor

Signature:

Title: Co-Founder, Vice President

Date: 11/21/2024