Birth Parent - Financial Worksheet 1 Guidelines & Agreement2 Financial Worksheet3 Anti-Fraud Agreement Before you begin the Financial Worksheet, please take a moment to review the Financial Policies (this link will open a new tab). Then return to this page and check the boxes below to indicate that you have read and agree to the statements.I understand I can only request expenses allowed by law as listed above.* Select All I understand I can only request expenses allowed by law as listed above. I realize that only on Monday all requested and approved bills will be paid. Additionally, I will receive a reloadable MasterCard. The agency will load money on that card to help me with expenses each Monday according to my financial plan. I agree that the week before a bill needs to be paid, I must tell my case manager, and provide documentation. She can request payment for the following Monday. It won’t get paid if I don’t let her know each time it is due, so I will call or text her 2 days or more, before Monday. I will also tell her if the weekly support is due the next Monday. I will select a family within a month of receiving financial aid, because I understand that funds come from the Adoptive Family that I choose. I recognize that this financial aid is intended as supplemental income. Additional resources such as income from a job, relatives, food stamps, Medicaid etc. will also be needed. I agree that I will have a conversation on the phone when my case manager requests it. I understand that all financial support Heart to Heart Adoptions may provide me is to support my effort to place my child for adoption, and assist me with pregnancy related expenses. It is my intention to select a family connected with Heart to Heart, and place my child for adoption with them. Name* First Last Your Due Date Your City/State* City State Where do you plan to deliver?*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificPhoneWe can help you get a basic phone or pay your basic phone bill. This can be paid on line or over the phone.My Phone* I don't have a phone I have a phone, but don’t need help paying for it. I need help To get help, please complete the info below.My Phone NumberMy phone carrier/companyPhone company's phone numberHow to payRentHeart to Heart may pay all or part of your rent if you need assistance with housing. We pay the rent directly to the landlord as often as possible. We will need your rental agreement and a receipt from the landlord when we pay. My Rent* I don’t need help with rent I need help To get help, please complete the info below.My Total Rent AmountRent Amount I need help withLandlord's NameLandlord's PhoneAddress to mail rent payment Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code UtilitiesWe can help with essential utilities. This doesn’t include back payments or deposits. These bills should be paid directly to the provider. You will need to upload a photo of the bill (or you can mail us a copy of your bill).My Utilities I don’t need help I do need help To get help, please provide utility information.Upload photos of the bills you listed below Drop files here or Accepted file types: jpg, png, jpeg. List the bills you need help withCompany NameAccount #Type of ServiceTotal BillAmount of help neededHow to pay Click the plus sign to add a new rowFood, Transportation, and Personal ItemsFor these items we will provide you with a reloadable MasterCard. We will add money to your card when scheduled. Click here for more information on your card. We will send your MasterCard in the mail as soon as we have received all your information.Food, Transportation, and Personal Items* I don’t need help I do need help I need these funds to help cover the costs of the following items: Recently, there has been an increase in fraudulent representations (fraud) from women claiming they want to place their child (born or unborn) for adoption. Fraud is committed when a woman falsely represents to an individual or an adoption agency that she intends to place her baby for adoption with them in order to receive services or money. This occurs when she lies about her intentions to place the baby for adoption, uses multiple agencies, requests and uses financial assistance to purchase things not related to the pregnancy. It is our desire to stop the fraud so we can better help birth mothers who sincerely need and desire our help. Therefore, we will prosecute women who commit this type of fraud.I understand I can only request expenses allowed by law as listed above.* Select All I understand that fraud is the intentional deception of a person or entity by another made for monetary or personal gain. I state that I will not accept services from Heart to Heart Adoptions unless I am certain I intend to place my baby for adoption with Heart to Heart Adoptions. I agree that I will not accept services from Heart to Heart Adoptions, while receiving services from any other person wanting to adopt my child or adoption service. Any financial assistance I receive from the agency will be used for the specific need requested. I will not work with other agencies, perspective adoptive families, or attorneys for the purpose of placing my child for adoption while receiving services from Heart to Heart Adoptions. I understand that the agency can prosecute for any fraud that occurs. Any statements made to others regarding my acts of fraud can be used against me in a court of law Your Email Address* Email PreferencesWe understand that, in some circumstances, it might not be a good idea to have proof of your communication with us in your inbox. So, please let us know your preference below.No. Please DO NOT email me a confirmation.Yes. Please send an email confirmation for my records.PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.