2021 Grant Cycle for Top Surgery Application

As a part of our mission to improve the health and well-being of the people in the communities we serve, BTMI is offering a grant of up to $1000 to assist with the  financial obligation for undergoing elective gender affirming top surgery for Black and African American trans men.    

Below, you will find information about the Black Transmen, Inc. Gender Affirming Surgery Financial Assistance Application. Completion of this application will enable us to review your request for consideration of financial assistance for your gender affirming surgery ONLY. 

The application can be found at the end of these instructions.

We greatly respect your privacy.  All information included in your application will be treated as confidential information with the exception of our verification process. All of your information will be restricted as internal information and only accessible to staff on a need to know basis. 

To be considered for this grant, please complete each item on the application in its entirety, including all required documents. You may submit the application online through this page. If you are unable to upload documents, please contact Charley Burton at CBurton@blacktransmen.org to arrange for an alternate submission process.

Before completing the application, we recommend that you review the following list of required documents, and have them ready to upload. You will not be able to complete and submit the application without these documents:

In addition to the documents listed above, the following information will be collected:

  • Your name 
  • Last 4 digits of Social Security #
  • Date of Birth
  • Current Address

Are you currently employed full-time? ______Yes _____No

Do you have medical insurance? ______Yes _____No

If yes, does your medical insurance cover a portion of your surgery expenses?

If so, how much?    ______Yes, it covers ______% or $____________ of the total bill.

No, my insurance does not cover my surgery and I am paying out of pocket via savings or a loan.

INCOME AND EXPENSES (Monthly amount):

Income (all sources) Gross $__________ Net $________

Mortgage/Rent $_______________

Utilities $_______________

Car Payment $_______________

Food/Groceries $_______________

Credit Cards $_______________

Other (please specify) $_______________

  • Financial Assistance Application

    As a part of our mission to improve the health and well-being of the people in the communities we serve, BTMI is offering a grant of up to $1000 to assist with the financial obligation for undergoing elective gender affirming, top surgery for Black and African American trans men.

    Completion of this application will enable us to review your request for consideration of financial assistance for your top surgery ONLY.

    We greatly respect your privacy. All information included in your application will be treated as confidential information with the exception of our verification process. All of your information will be restricted as internal information and only accessible to staff on a need to know basis.

    To be considered for this grant, please complete each item on the application in its entirety.

    IMPORTANT: Please review the instructions above so that you will have all documents ready to upload. You will not be able to submit the application until all fields are completed.

    If you are unable to submit the requested information through this form, you may also:

    1. Print and complete the application, and mail it -along with the required documents- to:

    Black Transmen, Inc. Attention: Charley Burton
    PO Box 8004
    Charlottesville, VA 22906

    Or

    2. Send all documents (in a single email) via email to cburton@blacktransmen.org

    If you have difficulty completing this application or there is an area that is unclear, please email your request for help to Charley at cburton@blacktransmen.org
  • About your income and expenses

    Please complete this section, and upload the required documents. If you have no expenses in any category, please enter $0. Please provide Monthly Income and Expenses.
  • Please provide copies of your current months pay stubs and/or proof of any other form of income for the household. If self-employed, please provide a copy of your most recently filed personal income tax return and a current profit and loss statement. Failure to provide the requested documentation can result in a denial for financial assistance consideration.
  • About your surgery

  • Please upload a 1500 (min) - 2500 (max) word essay on why this surgical procedure is important to you, and how BTMI can help you with your journey.
  • Additional required documents

    Please create documents, for each of the required documents below (using the text provided below), and sign (or ask your doctor to sign, as appropriate). Please include your (or your doctor's) full name and contact information. *OR*

    These required documents are available for download on the BTMI webpage:

  • "I hereby authorize BTMI to verify all information contained in this application for the evaluation of this application and I further certify the information provided is true and correct to the best of my knowledge. I am aware that this information will be used to determine my eligibility for financial assistance and that the falsification of information in this application may result in denial of BTMI Gender Affirming Surgery Financial Assistance. I also understand that any financial assistance approval may be completely or partially reversed in the event of a recovery from a third-party or other source." [SIGNED BY YOU]
  • I ________________________ give Black Transmen Inc. permission to use my name and a photo that I will provide to announce the recipient of the BTMI Surgery Fund. I am aware that my picture and name will be used on their website as well as any forms of social media.

    OR

    I ________________________ give Black Transmen Inc. permission to use my first name ONLY and I DO NOT wish to provide a photo to announce the recipient of the BTMI Surgery Fund. I will provide a personal testimonial to be published. I am aware that all information submitted (pictures, names and testimonies) will be used on their website as well as any forms of social media. Signature ____________________________________________
  • I ________________________________ give Black Transmen Inc. permission to speak with my surgeon, Dr. _____________________________. If eligible, BTMI will assist with remitting payment for medical services provided to me in the amount of $________ for my surgical procedure. Doctor’s office representative signature_________________________________ Doctor’s office representative printed name _____________________________Phone number _________________ Email _____________________________ Applicant signature____________________________________________________