GUIDELINES FOR ASSISTANCE *

Guidelines for assistance: The Travis Burkhart Foundation strives to provide assistance to those facing a sudden or prolonged illness, injury or diagnosis. We provide support in the form of gas/food cards, money for hotel costs and medical expenses related to the undergoing medical treatment of an individual. *Assistance request must be filled out by someone other than the recipient, requester (person filling out the form) must be a medical professional, friend or close family member and must be living outside of the recipients household. *Assistance is not guaranteed and is dependent on available funds and board approval. *Assistance is limited to one time a month or 30 days. *The Travis Burkhart Foundation does not provide assistance for day to day living expenses. *When redeeming gas certificates the recipient must be present, in some cases ID may be required. * TBF is not responsible for replacing lost or stolen assistance cards/certificates. *Assistance given must be honored responsibly and used for the sole purpose that is intended. *Any misuse of assistance could adversely affect future assistance. *Requests for an iPad/DME require a LOR (Letter of Recommendation) from a teacher, therapist or medical professional. *Assistance could be affected if there is an active Go Fund Me account. *Information provided must be detailed and thorough. *Must be a legal citizen in the United States **We do not cover vitamins, over the counter medications, supplements or basic nutrition products (i.e. formula and specialty milk)

I have read and understand the guidelines for assistance.

I am a legal citizen in the United States (requester)

The recipient is a legal citizen in the United States

Request for Assistance* *

Medical Verification, Letter of Recommendation and Documentation Policy We’re honored to be a small part of each recipient’s journey, and we hope the support provided by the Travis Burkhart Foundation (TBF) continues to make a meaningful difference in their lives. As we serve individuals and families across the nation—many of whom we’ve never met—it’s important that we maintain accurate and up-to-date records. To receive assistance, a Medical Verification Letter (MVL) must be submitted once per calendar year. 🩺 Medical Verification Letter (MVL) Requirements Your MVL must: *Be written on official letterhead from a licensed medical professional (doctor, therapist, or care provider). *Confirming that medical treatment is currently being received. *Include the full name of the individual for whom assistance is requested. This step allows us to be good stewards of the resources entrusted to us and ensures our mission is carried out with care, integrity, and compassion. ⚠️ Important Reminders *Assistance requests will not be reviewed or approved until a valid MVL is received. *Requests submitted without a current MVL will be denied until documentation is provided. *The requester (person submitting the form) must not be the recipient. Requests must be completed by a medical professional, friend, or family member on behalf of the individual in need. 💻 iPad Requests If you are requesting an iPad, a Letter of Recommendation (LOR) from a licensed medical provider (doctor, therapist, or care provider) is required along with the MVL. Your LOR must: *Be on official letterhead. *Include the individual’s full name. *Clearly state the reason for the recommendation. 📬 Submitting Your Documentation You may submit your MVL or LOR using one of the following methods: 📧 Email: travisburkhartfoundation@gmail.com 📬 Mail: The Travis Burkhart Foundation 10274 N 200 E Plainville, IN 47568 Providing the MVL or LOR at the time of application allows TBF to review your request more quickly and efficiently. The Travis Burkhart Foundation “Providing Hope and Support When It Matters Most.” *Letter of Recommendation (LOR) and/or Medical Verification Letter (MVL) is a letter written by a medical professional (doctor, therapist, or care provider) who can recommend an individual's need for assistance.

I am NOT a resident of Indiana, I am sending a Letter of Recommendation by mail

I am NOT a resident of Indiana, I am sending a Letter of Recommendation by email

I am NOT a resident of Indiana, I am willing to send a Letter of Recommendation if needed

I am a resident of Indiana

Medical Verification Letter (MVL) *

I am providing a current Medical Verification Letter (MVL) I am uploading or sending a current MVL on official letterhead from a licensed medical provider confirming that medical treatment is being received. Please note: Requests cannot be reviewed or approved until a valid MVL is received.

A current MVL is already on file with TBF I have previously submitted an MVL within the past 12 months, and there have been no changes in the recipient’s medical care or status.

I am referring an individual or family to the Travis Burkhart Foundation through a local contact or community partnership.

Request for iPad/DME *

****If you are submitting a request for an iPad/DME you will need to send in a Letter of Recommendation (LOR) from either the primary care doctor, teacher or therapist. It will need to be on their business letterhead and must include the individuals name that the iPad is being requested for. Please send the Letter of Recommendation (LOR) to travisburkhartfoundation@gmail.com or mail to TBF 10274 N 200 E Plainville, IN 47568. *We will supply a limited number of iPads each month. If the limited has been reached, we will notify you and you will need to reapply the following month. *Letter of Recommendation (LOR) is a letter written by a medical/educational professional who can recommend an individual's need for assistance.

I am sending Letter of Recommendation by mail

I am sending Letter of Recommendation by email

I am NOT requesting an iPad/DME

Is the recipient a minor? (under 18 years of age)? If so, or if the recipient has a legal guardian, please provide the information of the parent / guardian below. *

Yes

No

Parent / Guardian Name

First Name

Last Name

Parent / Guardian Phone Number

(###)

###

####

Relationship to recipient

Father

Mother

Custodial Grandfather

Custodial Grandmother

Guardian

Recipient Name (the name of the individual who is recieving medical care) *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

(###)

###

####

Other Phone

(###)

###

####

Does recipient have insurance? *

Medicaid

Medicare

Other

No

Unknown

Hospital where care is being given *

Daviess Community Hospital (Washington)

Good Samaritan Hospital (Vincennes)

Jasper Memorial Hospital

IU Health (Bloomington)

Deaconess (Evansville)

Riley Children's Hospital (Indianapolis)

St Vincent Hospital (Indianapolis)

Terre Haute Regional Hospital

IU Methodist Hospital (Indianapolis)

St Vincent Hospital (Evansville)

Peyton Manning Children's Hosptial (Indianapolis)

Greene County General Hospital

Other

Distance per round trip for medical treatment *

*Check the distance closest to what you travel.

20 miles

30 miles

40 miles

50 miles

60 miles

70 miles

80 miles

90 miles

100 miles

over 100 miles

over 150 miles

over 200 miles

Mode of transportation *

*Transportation is provided for medical appointments only.

Car

Airplane

SAFS (Senior & Family Services)

Ride Solutions

Other

If you are requesting gasoline for transportation to medical appointments please check the preferred station. *

*Gasoline is provided only for transportation to and from medical appointments.

Casey's

Hucks

Jones Oil (Montgomery / Loogootee IN)

Cantwell's Short Stop (Vincennes IN)

N/A

Requester Name *

First Name

Last Name

Address (where correspondence can be mailed) *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

(###)

###

####

Other Phone

(###)

###

####

Relationship to Recipient (person needing assistance) *

Aunt

Brother

Brother in law

Client

Cousin

Coworker

Daughter

Daughter in law

Father

Father in law

Friend

Granddaughter

Grandfather

Grandmother

Grandson

Husband

Mother

Mother in law

Neice

Nephew

Patient

Sister

Sister in law

Son

Student

Uncle

Wife