I hereby understand and recognize that the Shirley Mae Breast Cancer Assistance Fund (the “Fund”) is part of the Gold Foundation, a New Jersey nonprofit corporation which is a tax exempt organization pursuant to Internal Revenue Code Section 501 (c)(3). The Fund has been established for the benefit of those people diagnosed with breast cancer and to provide prescription, prosthesis, and/or selected or related items in support of an individual’s physical and emotional well being. The Fund will provide grants on an equal opportunity basis and without regard to an applicant’s sex, race, color, religion, creed, ethnicity, marital status or sexual orientation. However, the Fund is only authorized to provide assistance to those individuals who have a demonstrated financial need and live within the Service Area, as set forth in the Service Area section.

Accordingly, I hereby certify that the financial information set forth on this application concerning my annual household income, assets, liabilities and insurance provider is true and accurate, and that the purchase of goods and services that I have requested of the Fund to purchase on my behalf cannot be purchased by me and my family without incurring financial hardship. I further certify that I have been diagnosed with breast cancer and that I and my family do not have adequate insurance coverage which would pay for such goods and services that I have requested the Fund to purchase on my behalf. I understand that if any of the information set forth above is false, I am subject to punishment.