Caregiver Application

Moved By Love Foundation Application - Opening February 14, 2022

PART I – Tell Us About Yourself
Source of Income:
Total Monthly Expenses:
Please answer the following questions:
PART II – Tell Us About Your Family Member
Family Member/Patient:
Part III - Disclosure

The information contained in this application is for the purpose of obtaining assistance from the MOVED BY LOVE Foundation for the benefit of the undersigned (applicant). The application understands that the application will not be considered complete until all verification documents are submitted. Only applicants that are residents of New York are eligible to apply. The applicant understands that once the application is submitted, applicant will be contacted by a Representative for an interview and that process may take up to 30-60 days. The applicant understands that the information provided will be used in deciding whether to grant assistance and individually represents and warrants that the information provided is true and complete and that the MOVED BY LOVE Foundation may consider this statement as continuing to be true and correct. The applicant understands that the failure to provide accurate information and/or documentation or a material misstatement in this application will be enough to deny assistance from the MOVED BY LOVE Foundation. The MOVED BY LOVE Foundation is authorized to make all inquiries deemed necessary to verify the accuracy of the statements made on this application. The applicant grants to the MOVED BY LOVE Foundation the right to check any and all references with respect to the information contained in the application and the applicant waives any right to restrict the MOVED BY LOVE Foundation’s access to such information. Applicant understands that if such information is made unavailable to the MOVED BY LOVE Foundation, the MOVED BY LOVE Foundation may reject the application. All information will be kept confidential and will be used for the purposes intended.

Applicant understands that the MOVED BY LOVE Foundation has the right to fully audit the use of the donation at any time. Applicant also understands that the MOVED BY LOVE Foundation may use this application, if approved, for publicity and promotional purposes. We may also use applicant’s name on our website but any additional use of the applicant’s name for promotional purposes will receive prior approval from the applicant.