Apply for a Grant

*Please read through before applying for a grant using the online form below.

This grant is available for female and male applicants as part of their post mastectomy tattooing needs due to breast cancer and/or BRCA diagnosis

What is the Pink Ink Fund Grant for?

  1. This is a one time micro grant that will be given to chosen applicants who qualify for financial assistance with their post mastectomy(as a result of breast cancer or BRCA diagnosis)  tattoo services
  2. Each micro grant for the granting cycle of 2015 is for $200-250.
  3. Only 1 micro grant will be given per qualifying applicant. The micro grant may or may not be given to the same applicant again.

How do I apply?

1.Please read the requirements on our APPLICATIONS PAGE/FAQ

2.Applications may be completed via the online form below, or you by downloading and printing the Pink Ink Fund Financial Assistance Application here. Mail the completed application along with support documentation to:

Pink Ink Fund
3126 W. Cary Street
#248
Richmond, VA 23221

Who will be given a grant?

1.Pink Ink Fund is aiming to grant one applicant per US state in 2015! We hope the word spreads about our mission so that we can give away more micro grants per state for our next annual cycle.

Is there a deadline?

Our micro grants will be given away once a year right now, we hope to be able to do this more often as we grow!

Can I apply if I am active or retired military and/or a first responder?

Yes!

Can I apply if I have not had a mastectomy yet?

Yes, but we cannot guarantee you will be chosen for the micro grant.

Is there an age limit to apply?

No

Questions?

Please email us at: pinkinkfund@gmail.com.

Do not call. All questions must be emailed only.

Chosen applicants will be decided via a group of board members.

Please do not send extra correspondence such as: photos, personal letters outside of the application form, any correspondence from anyone other than the applicant and medical providers who may be referring the applicant.

Applying for the grant does not guarantee that you will receive one.

To apply for financial assistance you must complete/answer all FIVE steps below:

STEP 1. Please specify if your grant request is for:
 Nipple and areola tattoo/repigmentation Decorative mastectomy tattoo

STEP 2. Provide your contact information:
First Name

Last Name

Address

City

State

Zip/Postal Code

Phone Number

Email Address

STEP 3. Check all that apply:
 My insurance has denied coverage
 I do not have insurance
 I am a veteran
 I am a First Responder (Fire, Police, EMT)
 I am not a US citizen*

*If not a US citizen, please state the country in which you currently reside.

If you are not a US citizen, you may provide similar medical documents to the ones requested. (See additional steps below)

STEP 4. YOU MUST CHECK ONE OF THE BOXES BELOW.
I will send all relevant support documentation:
 Via e-mail Via postal service
(See below for details)

The following instructions for providing additional support documentation are required for grant consideration.

A. Provide a copy of your insurance’s Explanation of Benefits and letter stating a denial of coverage.

B. Provide a signed 1040 tax return for the previous year. To protect your privacy please black out your social security number(s). We do not need that.

C. Please include any doctor/medical providers’ referrals in reference to your mastectomy tattoo needs. Must include legible contact information including Name, Address, phone number and email of these referrals

You have 2 options to send supporting documentation (apart from submitting this form). You can email them to pinkinkfund@gmail.com. Or you can mail the supporting documentation to:

Pink Ink Fund
3126 W. Cary Street
#248
Richmond, VA 23221

You can also complete an application by downloading and printing the Pink Ink Fund Financial Assistance Application here. Mail a completed application along with support documentation to the address above.

STEP 5. Additional details you would like Pink Ink Fund to consider while reviewing your application:

PLEASE NOTE: If you are chosen as a Grantee, as part of your acceptance, we ask that you agree to supply us with a testimonial of photos or visuals and/or written feedback. This will be in support of helping others looking for our help and also aid us in continuing to uphold and improve our processes for our mission! If selected, you will be asked to complete and sign a copy of our Release Form, which can be found on our website listed above.

DISCLAIMERS:

1.Pink Ink Fund does not endorse any particular medical procedure or provider. Pink Ink does not endorse any tattoo artists. If you qualify for a grant, you will be wholly responsible for securing the tattoo procedure through your chosen service provider. Pink Ink Fund is not responsible for any work performed by third party tattoo artists or medical providers.

2.Pink Ink Fund does not share any information on applicants and will hold your personal information contained within this application private.

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