BASEBALL ASSISTANCE TEAM
BASEBALL ASSISTANCE TEAM
245 Park Avenue, 31st Floor
New York, NY 10167
212-931-7822
Fax: 212-949-5433
Toll Free: 866-605-4594
I. The following is an application for a Baseball Assistance Team (B.A.T.) Grant. Please fill out this application as completely as possible. Any blank areas may hold up the decision process, as government regulations require us to have detailed information. Once you have completed the form, return it to the address above. If you have any questions, please call.
IMPORTANT: ANSWER ALL QUESTIONS
(Please print in ink)
GENERAL INFORMATION TO BE COMPLETED BY APPLICANT
Name: _______________________________________________________ E-Mail: _______________________________________
Address: ____________________________________________________________________________________________________
City: _____________________________________ State: _________________________ Zip Code: _________________________
Date of Birth: _________________________________________ Home Telephone: ( ) ________________________________
Social Security #: ______________________________________ Work Telephone: ( ) ________________________________
In case of emergency, contact: Name: _____________________________________ Telephone: ____________________________
RELEASE OF INFORMATION
IN ORDER TO HELP YOU, B.A.T MUST BE ABLE TO VERIFY ALL INFORMATION
I authorize B.A.T. or its duly authorized representatives to contact, in person and/or by phone, all persons, creditors, banks, businesses, doctors, hospitals, and consultants and/or therapists, etc. listed herein for the purpose of verifying or obtaining additional information.
I further release B.A.T. and its duly authorized representative from any and all responsibility resulting from the release of any such information.
Signed: __________________________________________________________________ Date: ____________________________
Print Name: _________________________________________________________________________________________________
MARITAL STATUS
Single ( Married ( Widow/Widower ( Divorced (
Spouse Information:
Name: _____________________________________________________________________________________________________
Date of Birth: _________________________________________ Social Security #: ______________________________________
LIVING ARRANGEMENTS
Do you live alone? ( Yes ( No With another family ? ( Yes ( No
With spouse? ( Yes ( No With other relatives? ( Yes ( No
With children? ( Yes ( No In a retirement home? ( Yes ( No
Others? ( Yes ( No If yes, name of person ________________________
If you have children, please provide the following:
NAME BIRTHDATE SOCIAL SECURITY NUMBER
____________________________________ ________________________ ____________________________
____________________________________ ________________________ ____________________________
____________________________________ ________________________ ____________________________
____________________________________ ________________________ ____________________________
____________________________________ ________________________ ____________________________
BASEBALL EXPERIENCE / RELATIONSHIP
Please list teams and years of experience that you or your spouse had in the Major, Minor or Negro Leagues.
TEAM(S) YEAR(S)
___________________________________________________________________ ____________________________
___________________________________________________________________ ____________________________
___________________________________________________________________ ____________________________
___________________________________________________________________ ____________________________
___________________________________________________________________ ____________________________
___________________________________________________________________ ____________________________
If you or your spouse did not play baseball, what is your or your spouses connection to baseball? (Umpire, Front Office, etc.)
ORGANIZATION(S) YEAR(S)
___________________________________________________________________ ____________________________
___________________________________________________________________ ____________________________
___________________________________________________________________ ____________________________
___________________________________________________________________ ____________________________
INCOME
SOURCES OF INCOME (HOUSEHOLD)
Per Month Per Year
A.
Social Security ( Yes ( No _____________________________ ___________________________
Disability ( Yes ( No _____________________________ ___________________________
Baseball Pension ( Yes ( No _____________________________ ___________________________
Other Pension ( Yes ( No _____________________________ ___________________________
Veteran’s Benefits ( Yes ( No _____________________________ ___________________________
Other Sources ** ( Yes ( No _____________________________ ___________________________
Employment ( Yes ( No _____________________________ ___________________________
TOTAL (also record on page 6) _____________________________ ___________________________
** Interest Income from Mutual Funds (i.e. Vanguard Funds, Fidelity Funds, etc.) Stocks, Life Insurance Policies, Annuities, etc. or Major League Baseball Players Association Licensing Money
B.
Employment
Are you employed? ( Yes ( No
Employer’s Full Address and Phone Number: _______________________________________________________________
_______________________________________________________________
_______________________________________________________________
( ) __________________________
If you are unemployed: Are you able to work? ( Yes ( No
If you are unable to work, please list reasons:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
C.
Assets
Checking Account(s)
Bank: ________________________________________________________________________________
Bank Address: ________________________________________________________________________________
Phone Number: ( ) _________________________________________________________________________
Bank Account Number: ________________________________________________________________________________
Current Balance: ________________________________________________________________________________
Savings Account(s)
Bank: ________________________________________________________________________________
Bank Address: ________________________________________________________________________________
Phone Number: ( ) _________________________________________________________________________
Bank Account Number: ________________________________________________________________________________
Current Balance: ________________________________________________________________________________
D.
Other Assets
List all assets and their values if over $1,000 (i.e. money market, mutual funds, stock, permanent life insurance, autos, etc.). (If automobile(s), list make, year and estimated value).
ASSETS VALUE
_________________________________________________________________ ____________________________
_________________________________________________________________ ____________________________
_________________________________________________________________ ____________________________
_________________________________________________________________ ____________________________
_________________________________________________________________ ____________________________
_________________________________________________________________ ____________________________
_________________________________________________________________ ____________________________
_________________________________________________________________ ____________________________
_________________________________________________________________ ____________________________
OTHER ASSISTANCE
Are you receiving any public or private assistance?
If yes, please explain the nature of the assistance: _____________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________ ____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Who can we contact regarding the assistance you are receiving? ________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
EXPENSES
DWELLING EXPENSES
Mortgage: Is help needed with the mortgage? ( Yes ( No
If the answer is yes: What is the total amount of your mortgage? ____________________________
What is the value of your home? ____________________________
What is your monthly mortgage payment? ____________________________
Date of expected mortgage completion? ____________________________
Are you current with your payments? ( Yes ( No
Number of years at current address? ____________________________
If the answer is no: How many months are you behind with payments? ____________________________
Total amount needed to bring you current ____________________________
Please list the name and address of mortgage holder:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Telephone Number: ( ) ______________________________________________________________________________
Rent: Is help needed with the rent? ( Yes ( No
If the answer is yes: What is the total amount of your monthly rent? ____________________________
Are you current with your payments? ____________________________
Number of years at current address? ____________________________
If the answer is no: How far are you behind with your payments? ____________________________
Total amount needed to bring you current? ____________________________
Please list the name and address of landlord:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Telephone Number: ( ) ______________________________________________________________________________
HOUSEHOLD EXPENSES
MONTHLY EXPENSES
Food $____________________ Health Insurance $____________________
Clothing $____________________ Life Insurance $____________________
Transportation $____________________ Homeowners Insurance $____________________
Household Supplies $____________________ Auto Insurance $____________________
Maintenance Fees $____________________ Auto (Loan or Lease) $____________________
Mortgage/Rent $____________________ Child Care / Alimony $____________________
Cable / Dish $____________________ Prescriptions $____________________
Total Owed Average Monthly Bill Months Owed
Electricity ______________________ ________________________ ____________________________
Gas ______________________ ________________________ ____________________________
Water ______________________ ________________________ ____________________________
House Telephone ______________________ ________________________ ____________________________
Cell Phone ______________________ ________________________ ____________________________
TOTAL MONTHLY EXPENSES $________________________________
TOTAL MONTHLY INCOME $__________________________________
(From Total on Page 3)
UTILITIES
Is help needed with the utilities? ( Yes ( No
If the answer is yes:
Are you current with your payments? ( Yes ( No
If the answer is no, what is the total amount to bring you current? $______________________
PLEASE LIST ALL CREDITORS, INCLUDING AUTOS:
Name Address Amount Account Number
____________________ __________________________ _________________ _________________
____________________ __________________________ _________________ _________________
____________________ __________________________ _________________ _________________
____________________ __________________________ _________________ _________________
____________________ __________________________ _________________ _________________
NOTE: These expenses must be documented with copies or the actual bills when requested.
DO NOT SEND BILLS AT THIS TIME.
MEDICAL
Is help needed for your medical needs? ( Yes ( No
If the answer is yes, describe your medical needs or disabilities: _________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Are you covered by : Medical Insurance ( Yes ( No Dental Insurance ( Yes ( No
Medicare ( Yes ( No Medicaid ( Yes ( No
Other ______________ ( Yes ( No
HOSPITAL
Is help needed with a hospital? ( Yes ( No
If the answer is yes, what is the total of your bill? _____________________________________________________
Are you current with your payments? ( Yes ( No
If the answer is no, how many months are you behind with your payments? ________________________________
What is the amount needed to bring you current?______________________________________________________
(If answer is yes, and help is needed, you must fill out the enclosed medical expense form).
DOCTORS
Is help needed with doctors? ( Yes ( No
If answer is yes, what is the total of your bill? ________________________________________________________
Are you current with your payments? ( Yes ( No
If answer is no, how many months are you behind with your payments? ___________________________________
What is the amount needed to bring you current? _____________________________________________________
(If answer is yes, and help is needed, you must fill out the enclosed medical expense form).
If there is a need for continuing doctor’s care, please list the reasons.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Should you feel a need to add more information, please feel free to use this space. We would appreciate any additional information you would like to provide us.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
BASEBALL ASSISTANCE TEAM
245 Park Avenue
34th Floor
New York, NY 10167
(212) 931-7821/7822
Name: ______________________________________________________________________________________________
Address: _____________________________________________________________________________________________
City: ________________________________________________ State: ___________________ Zip: __________________
Home Telephone: ( ) ________________________________ Work Telephone: ( ) __________________________
If I am not available, please contact:
Name: _______________________________________________ Telephone: ( ) _______________________________
| |MEDICAL BILLS (Doctor/Hospital/Prescriptions) | |
|DATE |* DO NOT SEND BILLS AT THIS TIME * |AMOUNT |
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GRANT APPLICATION
GRANT APPLICATION
GRANT APPLICATION
GRANT APPLICATION
GRANT APPLICATION
GRANT APPLICATION
GRANT APPLICATION
GRANT APPLICATION
MEDICAL EXPENSE FORM
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