**PLEASE
READ ALL GRANT MATERIALS BEFORE FILLING OUT
THE APPLICATION**
The Pay It Forward Fertility Foundation Board of Directors will select applicants who are uninsured for
fertility treatment for a grant that can be used toward fertility treatment at a fertility clinic that is a
member of the Society for Assisted Reproductive Technology (SART).
Applications may not be received by fax or email. All applications must be mailed. Applications that
are mailed late, that are incomplete, and/or not received by mail will automatically not be
reviewed.
The first due date for 2015 will be May 31, 205. The foundation is evaluating application procedures
and will release the due dates for the rest of 2015 after June 1, 2015.
While we would love to offer grants to every applicant, not all applicants will receive grants. The grant
amounts vary among the grant recipients, and partial and full grants can be awarded. What is
covered (i.e. monitoring, lab work, medications, procedures, etc.) under the grant amount will be
disclosed to each of the grant recipients at time of award and funds from the grant will be given
directly to the clinic.
There is a $50 application fee for each application submitted. This fee is NONREFUNDABLE. If
you decide to withdraw your application between the time that you submit and the board has made a
decision, the foundation will still not refund the fee. The application fee is considered a donation and
the foundation can provide any paperwork you would need to document the donation. The fee needs
to be in form a check made out to: Pay it Forward Fertility Foundation for $50 and to be submitted
with application.
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Below is a brief description on the grant process once an application has been
submitted:
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The application is received into the mailbox for PIFFF and must be postmarked by the due
date
The application packet is opened and checked for completeness
All applicants receive an email that their application has been received and is moving forward
for further review
At further review, the application is again checked for completeness and thoroughly read and
reviewed
Application is passed on for financial review
Application is then put in front of Medical board for medical viability
Then applications are put in front of Board of Directors for final vote
Background check is run on applications voted on
Couple(s) are notified that are receiving grants
Once those couples accept, then we notify all other applicants of board decision
Please do not contact the foundation during the 6-8 week review process; the foundation is
busy reviewing applications; the foundation will contact you if they need more information. The
foundation understands that this is a trying time for infertility patients, but know that the
foundation works diligently to get the selection as soon as they can.
This whole process does tale the entire 6-8 weeks as we are an all volunteer board. We do not
take these decisions lightly so we will not rush them.
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REQUIREMENTS FOR THE GRANTS
 Applicants must demonstrate financial need and be uninsured for fertility
treatments.
 Female patient must be under the age of 40 when starting an IVF cycle.
 The foundation’s board of directors will consider female patients who are over 40
and are doing IVF with donor eggs or adopting an embryo through frozen embryo
transfer.
 All monies received through the Pay it Forward Fertility Foundation must be used
within 365 days of the award date.
 Patients with no children already will be given priority.
 Patients who have already spent funds on fertility treatment will be given priority.
 All monies will be paid directly to participating clinic; no monies will be given
directly to the patient.
 The grant may not be used to reimburse the patient, nor the clinic, for the
services already received; the grant cannot be used for services that have
already been performed, nor loans that have that already been secured; the
grant is used towards future cycles.
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 All grant recipients will be subject to a criminal background check and a credit
check.
 You must meet the American Society for Reproductive Medicine definition of
Infertility (i.e. blocked tubes, unexplained infertility, endometriosis, PCOS, male
factor, female factor, etc.). A fertility specialist must officially diagnose infertility.
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Reminders about the application:
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Applications must be post marked by due date
Late applications will not be considered
Applications that are received by fax and/or email will not be considered
Application fee of $50 needs to be submitted at the same time of the
application
 Do NOT bind the application, staple the application, paper clip the
application, enclose the application in a folder, and/or enclose the
application in a binder.
 PLEASE include the completed checklist with the complete application
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FREQUENTLY ASKED QUESTIONS
Must both partners be U.S. citizens?
Applicants must be United States (U.S.) citizens or permanent U.S. residents.
Do we have to be residents of Texas and/or use a clinic in TX?
No, you do not have to be a TX resident. You can use any SART certified clinic in the US.
What is the Pay It Forward Fertility Foundation Grant?
The Pay It Forward Fertility Foundation grant is a grant that awards funds toward fertility treatments, such as in vitro fertilization
(IVF), IVF using donor eggs and embryo adoption.
How often is the grant awarded?
Grants are awarded several times a year based on Board of Directors’ meetings.
How many grants are awarded?
The number of grants awarded each year will vary and are contingent upon availability of funds. You are encouraged to carefully and
thoroughly answer each section of the application. We also encourage you to seek additional sources of fertility treatment funding.
How will the grant monies be distributed?
The Pay It Forward Fertility Foundation will work with the grant recipient in organizing payments to a certified fertility clinic in the
United States for fertility services received.
Does the grant apply to intrauterine insemination (IUI) and other procedures?
The grant applies only to in vitro fertilization treatment (IVF), IVF with donor eggs and embryo adoption.
What IVF costs are covered by the grant?
The grant money can be used toward any of the costs of IVF (monitoring, ultrasounds, anesthesia, retrieval, fertilization and culture of
the egg, transfer, etc.). Depending on the amount of grant money awarded, it may or may not cover all costs associated with the
patient’s cycle. (Excludes blood work)
Will the grant cover a Frozen Embryo Transfer (FET) cycle?
Yes, if it is for embryo adoption, from a certified fertility clinic that has an embryo adoption program.
Is fertility medication considered part of the costs of IVF?
No. Fertility medication is a separate expense not covered by the grant. Some or all of your fertility medications may be covered by
your prescription coverage, or may be an out of pocket expense.
Can the time for using the grant be extended beyond one year?
The grant time limit has been established for awarded funds to be used within 12 months from the date of award. Special consideration
will be given to patients who are deployed through the U.S. military or are in treatment for cancer.
Is there an age limit?
Yes, the age limit for the female partner is under 40 years old, unless using donor eggs or doing embryo adoption. The application
states that the female patient must be under the age of 40 when starting an IVF cycle; if over 40 and using own eggs, applicant must
provide justification that using own eggs is a viable option per current physician.
Can you have children already?
Yes, but the selection process is preferential for those without children and for those who have already spent funds on fertility
treatment.
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Is there an annual minimum or maximum income?
There is no minimum or maximum. The tax returns and answers to financial question must reflect an ability to financially support a
child. However, the amount you have already spent out of pocket on fertility treatments will be taken into consideration.
What if I have incomplete medical insurance coverage?
You must have medical insurance and be able to provide proof of medical insurance to cover your health care needs. Grants will be
awarded only to those without any fertility insurance coverage or IVF medical insurance coverage.
Do I need to provide a physician's written recommendation?
A physician's recommendation for fertility treatment is required. We encourage you to provide a letter from a physician or a copy of
your fertility work-up with your application. The date on the documents should be within the past year.
Do I need to have male partner?
No, but clarification of relationship stability is required.
Can a single person apply for the grant?
Yes. However, we suggest the application contain detailed information on the applicant's support system, stability and overall plan to
raise a child alone.
If I am considering or need egg donation to pursue IVF, may I apply for the grant?
Yes, you may submit an application for the grant. You must state your plan for egg donation and the ability to afford the cost of egg
donation.
If I am pursuing an IVF cycle with a surrogate carrying the pregnancy, may I apply for the grant?
Yes, you may submit an application for the grant. Your must state your surrogacy plan and ability to afford the cost of surrogacy.
Can the grant be used for IUI and/or frozen embryo transfer?
No, the grant can only be used for IVF, IVF with ICSI, IVF with donor egg, or IVF with embryo adoption.
Grants will be awarded as selected by the Pay It Forward Fertility Foundation Board of Directors. Applicants will be asked to
complete a confidential application. They will also be asked to write a short essay describing their infertility history, personal situation
and financial need. Proof of income and other supporting financial documentation will be required.
Completed applications and other required documentation should be sent to:
Pay It Forward Fertility Foundation
19141 Stone Oak Pkwy, Ste. 104-12
San Antonio, TX 78258
[email protected]
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APPLICATION CHECKLIST
PLEASE COMPLETE CHECKLIST AND SEND IT BACK WITH APPLICATION
(Please do not staple, bind, etc. any parts of application)
ONLY COMPLETE APPLICATIONS WILL BE CONSIDERED
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1. Signed Copyright and Media Release Form (included in this
application packet)
2. Certification of Application (included in this packet)
3. Applicant Summary Sheet
4. Applicant(s) Personal Information form (included in this application
packet)
5. List of all previous fertility treatments and monies spent
6. Letter from your current fertility specialist. (A letter is included in
this application packet that should be printed off and given to your
physician. Physician can mail directly to PIFFF or give to
applicant)
7. Financial Affidavit (included in this application packet)
8. Written description of infertility history/story from each partner
(separate document that the applicant provides)
9. Proof of income with documentation: This is to include:
a. A copy of the last TWO IRS tax returns for each party on the
application in their entirety (i.e. any schedules (if applicable)
must also be accompanied with the tax return
b. A copy of the TWO most recent pay stubs from each party on
the application
10. A photocopy of BOTH sides of the applicant’s insurance card
and the applicant’s partner’s insurance card.
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When the checklist is complete, mail (mail only) the application to the address below:
Pay It Forward Fertility Foundation
19141 Stone Oak Pkwy, Ste. 104-12
San Antonio, TX 78258
[email protected]
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MEDIA RELEASE FORM
_____I/we grant permission to the Pay it Forward Fertility Foundation and its subsidiaries and
sponsors to use my/our name and/or photographs or video media in printed or electronic matter for
use in publication and marketing materials. I/we further authorize the above entities to use my/
our name(s) and/or photographs or video media, or printed or electronic matter on its website or other
electronic forms of media (“marketing materials”).
_____I /we hereby waive any right to inspect or approve the ﬁnished photographs or video media in
printed or electronic matter that may be used now or in the future, whether that use is known to me/us
or unknown, and I/we waive any right to royalties or other compensation arising from or related to the
use of the photographs or video media in printed or electronic marketing materials.
_____I/we herby agree to release, defend and hold harmless the Pay it Forward Fertility Foundation
and its subsidiaries, including any ﬁrm publishing and/or distributing the ﬁnished product in whole or
in part, whether on paper or via electronic media, from and against any claims, damages or liability
arising from or related to the use of the photographs or video media in marketing materials.
_____ I/we have read this release before signing below and fully understand the contents, meaning
and impact of this release. I/we understand that I/we am/are have had an opportunity to address any
speciﬁc questions regarding this release by submitting those questions to Pay it Forward Fertility
Foundation in writing prior to signing, and/or by consulting a professional of my own choosing and
I/we agree that my/our failure to do so will be interpreted as free and knowledgeable acceptance of
the terms of this release.
Date: _______________________
Applicant’s Name: (Please print)
___________________________________________________________________
Partner’s Name: (Please print)
__________________________________________________________________
Address:
________________________________________________________________________________
________________________________________________________________________________
Applicant Signature:
______________________________________
Applicant’s Partner Signature: ______________________________________
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CERTIFICATION OF APPLICATION
Please be sure to read over your application before sending it in. I/We the
undersigned declare my/our application to be the full truth to the best of my/our
knowledge.
Signature of Applicant: ________________________________________________
Signature of Applicant’s Partner: _________________________________________
I/we authorize verification of the information contained in this application via
credit history, criminal history checks and other means. Please note that all
grant awards are contingent upon background and credit checks on both parties
of the application.
Signature of Applicant: _________________________________________________
Signature of Applicant’s Partner: _________________________________________
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SUMMARY SHEET
Please fill out as much information as possible on this sheet. Some/most of this information can be
found from your history and/or the letter from your physician.
In regards to female receiving procedure:
Age
AMH:
AMH Reserve:
BMI:
How many:
IVF _____
IVF w/ ICSI _______
IVF w/ Donor Egg_________
Results from semen analysis:
Notes on uterine cavity:
Total money spent on infertility so far: $_____________
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APPLICANT PERSONAL INFORMATION
(“Applicant” refers to the person who will be receiving the embryo implantation)
APPLICANT INFORMATION:
LAST NAME: ___________________FIRST NAME: _______________MIDDLE INITIAL: _______
STREET ADDRESS: _______________________________________________________________
CITY: ____________________________________ STATE: _________ ZIP: _________________
HOME PHONE: ______________________________
MOBILE PHONE: ________________________ WORK PHONE: __________________________
EMAIL ADDRESS: _______________________________________________________________
DATE OF BIRTH: ___________________________ AGE: ____________ SEX: ____________
SOCIAL SECURITY NUMBER: _____________________________________________________
OCCUPATION: __________________________________________________________________
EMPLOYER NAME AND PHONE: __________________________________________________
DATE EMPLOYMENT BEGAN: ________________________ SALARY: ___________________
NAME OF PREVIOUS EMPLOYER: ________________________________________________
DATES OF EMPLOYMENT: _______________________________________________________
JOB TITLE AT PREVIOUS EMPLOYER: _____________________________________________
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APPLICANT PERSONAL INFORMATION (cont.)
APPLICANT’S PARTNER INFORMATION:
LAST NAME: ___________________FIRST NAME: _______________MIDDLE INITIAL: _______
STREET ADDRESS: _______________________________________________________________
CITY: ____________________________________ STATE: _________ ZIP: _________________
HOME PHONE: ______________________________
MOBILE PHONE: ________________________ WORK PHONE: __________________________
EMAIL ADDRESS: _______________________________________________________________
DATE OF BIRTH: ___________________________ AGE: ____________ SEX: ____________
SOCIAL SECURITY NUMBER: _____________________________________________________
OCCUPATION: __________________________________________________________________
EMPLOYER NAME AND PHONE: __________________________________________________
DATE EMPLOYMENT BEGAN: ________________________ SALARY: ___________________
NAME OF PREVIOUS EMPLOYER: ________________________________________________
DATES OF EMPLOYMENT: _______________________________________________________
JOB TITLE AT PREVIOUS EMPLOYER: _____________________________________________
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APPLICANT PERSONAL INFORMATION (cont.)
(“Applicant” refers to the person who will be receiving the embryo implantation)
CHILDREN LIVING IN YOUR HOUSEHOLD (part time and full time):
NAME
DATE OF BIRTH
BIOLOGICAL PARENTS
HAS THE APPLICANT EVER BEEN PREGNANT?
YES
NO
IF YES, HOW MANY TIMES? ________ HOW MANY LIVE BIRTHS? ________ LOSSES? ______
HAS THE APPLICANT’S PARTNER EVER PRODUCED A PREGNANCY?
YES
NO
IF YES, HOW MANY TIMES? ________________
DOES THE APPLICANT OR THE APPLICANT’S PARTNER HAVE ANY CHILDREN AT ALL?
YES
NO
HAS THE APPLICANT EVER HAD AN IVF PROCEDURE?
YES
NO
YES
NO
IF YES, HOW MANY TIMES? _________________________
DOES THE APPLICANT HAVE ANY FROZEN EMBRYOS?
IF YES, WHERE ARE THEY KEPT? ________________________________________________
WITH WHAT PHYSICIAN (S) AND/OR CLINIC (S) HAVE YOU BEEN TREATED WITH
INFERTILITY?
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APPLICANT PERSONAL INFORMATION (cont.)
DATE OF MARRIAGE BETWEEN APPLICANT AND APPLICANT’S PARTNER: _______________
IF NOT MARRIED, PLEASE EXPLAIN WHY:
HAS THE APPLICANT OR THE APPLICANT'S PARTNER EVER BEEN CHARGED, DETAINED
OR ARRESTED FOR A FELONY OR MISDEMEANOR THAT WAS RESOLVED BY CONVICTION,
PROBATION, DEFERRED ADJUDICATION, COURT ORDERED COMMUNITY SUPERVISION OR
PRETRIAL DIVERSION OR THAT HAS NOT BEEN RESOLVED BY ANY METHOD? IF YES,
PLEASE GIVE ALL DETAILS.
HAS THE APPLICANT OR THE APPLICANT’S PARTNER EVER BEEN TREATED FOR
SUBSTANCE ABUSE?
YES
NO
IF YES, PLEASE EXPLAIN:
HAS THE APPLICANT OR THE APPLICANT’S PARTNER EVER BEEN TREATED FOR A
MENTAL ILLNESS?
YES
NO
IF YES, PLEASE EXPLAIN PLEASE PROVIDE DOCUMENTATION NOTING STABILITY:
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APPLICANT PERSONAL INFORMATION (cont.)
(“Applicant” refers to the person who will be receiving the embryo implantation)
HEALTH INSURANCE INFORMATION
PLEASE ATTACH A PHOTOCOPY OF BOTH SIDES OF THE APPLICANT’S INSURANCE CARD
AND THE PARTNER’S CARD.
DOES THE APPLICANT HAVE PRENATAL COVERAGE?
YES
NO
DOES THE APPLICANT HAVE COVERAGE OR THE ABILITY TO ADD COVERAGE FOR A
CHILD?
YES
NO
DOES THE APPLICANT OR THE PARTNER HAVE ANY INSURANCE COVERING INFERTILITY
PROCEDURES, MEDICATIONS, DIAGNOSIS, AND/OR TREATMENT? PLEASE BRIEFLY
SUMMARIZE BELOW THE BENEFITS RELATED TO FERTILITY TREATMENT FROM THE
INSURANCE POLICY AND HISTORY OF BENEFITS RECEIVED FROM FERTLITY RELATED
TREATMENTS.
DO YOU KNOW YOU WILL NEED IVF WITH DONOR EGG?
YES
NO
IF YES, DO YOU KNOW WHO YOUR EGG DONOR WILL BE?
YES
NO
IF YOUR KNOW EGG DONOR, PLEASE GIVE PROIVDE THE FOLLOWING INFO FOR THE EGG
DONOR:
AGE:
AMH:
ANY PREVIOUS PREGNANCIER
YES
IF YES, HOW MANY LIVE BIRTHS? ANY COMPLICATIONS?
NO
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FINANCIAL AFFIDAVIT
Gross MONTHLY Income from All Sources
1. Base pay from salary, wages $ __________________
2. Self Employment Income $__________________________
3. Income from overtime-commissions-tips-bonuses-part-time job
$__________________
4. Dividends - interest $ _____________________
5. Income from trusts or annuities $ ____________________________
6. Pensions and retirement funds $ _____________________________
7. Social Security $ ______________________
8. Disability, unemployment insurance or worker's compensation $____________
9. Public Assistance (welfare, A.F.D.C. payments) $ _______________________
10. Income Producing Property $ _______________
11. All other sources $ _____________________________
12. NET base income from salary, wages $_______________
List ALL Joint and Individual Applicant Assets
(Attach additional pages if necessary)
1. List all Property owned including property location/s and Fair Market Values
a. _________________________________________________
b. _________________________________________________
c. _________________________________________________
2. List pension fund values $ _________________________________
(IRA, Pension, Profit Sharing, Other Retirement Plans, etc.)
3. Life Insurance: Present Cash Value $ ______________________
4. Savings account/s Balance: $______________________________
5. Money Market Accounts, and CDs values: $ _________________
6. Motor Vehicles (year, make and model plus approximate Blue Book Values
http://www.kbb.com)
a. Year:______Make:________Model______________Value___________
b. Year:______Make:________Model______________Value___________
c. Year:______Make:________Model______________Value___________
7. Other (stocks, bonds, collections, boats, RVs) $_________________________
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FINANCIAL AFFIDAVIT (cont.)
List ALL joint and individual applicant LIABILITIES (attach separate
sheet if necessary).
Creditor
Nature of
Liability
Date Amount Owed Monthly
of
Payment
Origin
1st
Mortgage
2nd
Mortgage
Monthly
Rent
Automobile
Automobile
Student
Loans
Please list all credit cards and their outstanding balances (attach
separate sheet if necessary).
Credit Card(s) and Other
Name
Balance
Please list any payments to and or from Alimony and/or child support:
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FINANCIAL AFFIDAVIT (cont.)
Are or were there any liabilities/credit cards in collection? _______________________
_____________________________________________________________________
Have you ever filed bankruptcy? __________________________________________
Do you have/had a home in the foreclosure process? __________________________
Applicant comments/notes about finances:
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PLEASE LIST ALL PREVIOUS INFERTILITY TREATMENTS:
DATE
PROCEDURE
OUTCOME
TOTAL$
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PHYSICIAN LETTER
(PLEASE PRINT THIS LETTER AND GIVE TO YOUR CURRENT FERTILITY
SPECIALIST)
Dear Doctor,
Your patient has applied to the Pay it Forward Fertility Foundation for financial assistance for fertility
treatment. Pay it Forward Fertility Foundation is a 501(c)(3) nonprofit organization that administers
grants to qualified patients seeking in vitro fertilization. In order to expedite the processing of your
patient’s application, we ask that you provide a letter summarizing your patient’s care. Please
include:
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The reason for infertility
Comments on semen analysis
Comments on uterine cavity
Comments on patency of tubes and ovarian reserve (ideally AMH level)
AMH reserve
Patient’s BMI
Do you consider this patient a good candidate for IVF, IVF with donor egg, or embryo
adoption?
Thank you so much for your time and cooperation!
Best regards,
Pay it Forward Fertility Foundation
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