Financial Grant Application - Australian Jewish Fertility Network

Your Details

Your first name

Your last name

Your age

Your DOB

Your email

Your Phone/Mobile

Relationship status

Partner's first name

Partner's last name

Partner's DOB

Partner's email

Partner's Phone/Mobile

Is your partner Jewish?

Yes

No

Your Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Do you qualify for Medicare?

Yes

No

Are you Jewish?

Yes

No

If you were married by a Rabbi please provide the Rabbi’s name and contact details

Have you been previously supported financially by AJFN?

Yes

No

How did you hear about AJFN?

Other (please specify)

Medical / Fertility background

How long you have been trying?

Briefly describe your fertility background and diagnosis

Have you had successful treatment in the past?

Do you have children conceived naturally?

Medical advice received

Do you require PGD/T testing?

Do you have an approximate date for the fertility treatment?

Yes

No

Date of fertility treament

Financial assistance

Your occupation and employer

Current employment status and how long have you worked at your current job?

Partner occupation and employer

Partner current employment status and how long have they worked at their current job?

What is your approximate combined annual income (Gross and Net)?

Please include copies of three of the most recent Payslips and a copy of the last financial year’s tax return

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For you and your spouse/partner (if unable to upload, please liaise with AJFN to send directly)

Do you own your own home?

Yes

No

Do you own an investment property?

Yes

No

Do you own any assets (including your own home - if you own one - investments, businesses, property, shares)?

Yes

No

If yes, then what is the net value of your assets?

If yes, do you have any additional sources of income (such as family support or income from investments)? If so, please describe the income and the value of that income in a financial year?

Do you have any liabilities/loans?

Yes

No

If the answer is yes then what is the net value of your liabilities/loans?

Approximately how much have you paid (out-of-pocket) to date for any treatments directly related to your fertility journey?

Have you incurred any debt as a result of your fertility treatments?

Yes

No

If you do have debt incurred during your fertility treatment, what is the amount of this debt?

What are your top 3 major monthly expenses? Please list them.

For example:
Rent/mortgage repayments $4000
School fees $2000
Food $1500

Do you (as the recipient of fertility treatment) qualify for Medicare?

Yes

No

Have you reached Medicare safety net?

If partial, how much to reach?

Do you have private health insurance?

Yes

No

If so, is any part of the fertility treatment covered by your insurance?

Fertility Treatment costs

Note: AJFN looks to support a portion of the out-of-pocket treatment costs based on a number of factors, including history, diagnosis, age, income of the couple applying and previously incurred costs, amongst other things. We are not in a position to cover entire treatment costs.

Please indicate total expenses for your upcoming treatment after the Medicare rebate?

Please attach any quotes/invoices/bills

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(if unable to upload, please liaise with AJFN to send directly)

Letter from Doctor explaining your diagnosis and suggested treatment plan

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Have you applied for any other financial assistance other than AJFN (e.g. other organisations)? If so, from where and how much?

Counselling grants

Where counselling is sought to support you on your fertility journey, AJFN may contribute towards covering a portion of the out-of-pocket expenses for psychologist fees.

Please indicate if you would like to seek this assistance and provide referral letter with name of counsellor/psychologist prior to sessions. To enquire further about this assistance contact [email protected].

Please indicate if you would like to seek this assistance

Yes

No

Provide referral letter with name of counsellor/psychologist

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