Application for Financial Assistance

Use this form to apply for financial assistance for out-of-hospital birth with a certified nurse midwife or to hire a doula for in-hospital birth. Our out-of-hospital birth assistance is $3000, our doula assistance is $500.

We suggest filling this out application out on a computer as you'll need to upload documents at the end of the application. If you are unable to upload here or while filling this out on a mobile device, you can email the documents to office@communitybirthfund.org.

Applications are accepted from the 1st-20th of each month. Applications are reviewed starting the 20th of the month and decisions are emailed the first week of the following month.

To be eligible, you most be a pregnant woman living in the Permian Basin who can prove financial need.

Application

Please fill out the following information for the Mother.

First Name

Phone Number

Last Name

Street Address

City

Date of Birth

Occupation

How many pregnancies have you experienced?

How many births have you experienced?

Due Date

Please fill out the following information for the Father.

First Name

Phone Number

Last Name

Street Address

City

Date of Birth

Occupation

Please fill out the following information regarding the Household.

Annual Household Income

Household Size

Tell us why you need financial assistance to help pay for birth

Mother's Personal Statements

Tell us why you are interested in having an out of hospital birth or a doula for your in-hospital birth?

Anything else you'd like to share with the selection commitee?

Supporting Documentation

Please upload the following:
- A copy of your insurance card
- Prior year tax return for both mother and father
- 3 months of your most recent pay stubs for both mother and father
Applications will not be processed without these documents. You can also email these files to office@communitybirthfund.org.

Upload File

Thanks for submitting! A response will be emailed the first week of the next month.