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:
- Authorization to collect necessary information
- Authorization to Contact Surgeon
- Release form
- Copy of current month’s pay stub 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.
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 $________
Car Payment $_______________
Credit Cards $_______________
Other (please specify) $_______________