2022 DONOR APPLICATION WORKSHEET LIVING ORGAN DONATION REIMBURSEMENT PROGRAM

Page 1 of 9

First name Last name Date of birth Social Security number

Important: Full name must match the name on your Social Security card

Sex Race Ethnicity Marital status Education

Male

Female

American Indian or Alaska native

Asian

Black

Native Hawaiian or other Pacific Islander

White

Hispanic

Not Hispanic

Married

Single

Divorced/separated

Widowed

Grade school

High school/GED

Post HS/tech or trade

Some college

4-year college

Post college/professional

Employment status Organ Please answer:

Employed full-time

Employed part-time

On disability leave

Retired

Homemaker/caretaker

Student

Unemployed

Kidney

Liver

Lung

Uterus

Are you a U.S. citizen or lawfully present resident?

Have you signed the NLDAC Attestation Form? (see page 4) The NLDAC Program will make it possible for me to be an organ donor. Are you self-employed?

Yes No

Yes No

Yes No

Yes No

Relationship to transplant candidate

I am the _________________ of the recipient. Father Mother Sister Brother Son Daughter Spouse Other

If other, please specify:

TYPE OF RELATIONSHIP: Blood related Non-blood related (by marriage, in-law, etc.) Unrelated

Address of primary residence Check if donor and recipient live at the same address.

Street: City: State: Zip:

Location: Urban Suburban Rural

Cell: Alt. phone: Email address:

If application is approved, we will send approval letter by email

Send reimbursement to address of primary residence? Yes No If no, provide alternative address:

Street: City: State: Zip:

HOUSEHOLD INCOME INFORMATION: Combine the incomes of all members of your household. The transplant professional who files your application will confirm and record household income based on the document(s) you provide.

Yearly household income: $ Persons in household: #

Select the income document used to verify your household income and give a copy to your transplant professional.

Federal income tax return - most recent year (use adjusted gross income)

Pay stubs (use gross income)

W2 (use gross income)

Government assistance program (HUD, WIC, SNAP)

Medicaid eligibility

Social Security benefits statement

Other document - (i.e. disability statement, etc.)

Instructions: NLDAC helps eligible living organ donors with their travel expenses, lost wages, and dependent care expenses. To apply, the donor and their recipient must complete these application worksheets, attach a copy of a document that verifies their household income, and send their application to a transplant professional (social worker, nurse coordinator, etc.), who will submit the application to NLDAC. Donors who are applying for reimbursement of lost wages and/or dependent care must also submit a W-9(lost wages and dependent care) and two pay stubs (lost wages only), in addition to their household income document. Do not sendyour application materials to NLDAC. NLDAC can only accept applications from transplant centers. Applications must be approvedbefore surgery, and NLDAC cannot reimburse expenses incurred before the application is approved. Application review takes 15

What type(s) of assistance would you like from NLDAC?

Reimbursement of travel expenses Reimbursement of lost wages Reimbursement of dependent care expenses

business days. For more information, call NLDAC at (888) 870-5002.

Page 2 of 9

REQUEST FOR REIMBURSEMENT OF LOST WAGES (optional)

Instructions: To apply for reimbursement of your lost wages, follow steps 1, 2, and 3 below. This section is optional, and you can skip it if you would only like help with travel expenses and/or dependent care. NLDAC will use your pay stubs or tax forms to calculate your wage reimbursement. NLDAC can only reimburse documented income. Call (888)870-5002 if you have any questions or need help identifying the correct income document.

Step 1: Complete this pageStep 2: Complete and sign IRS Form W-9Step 3: Attach your income document

If you are an employee, attach your two most recent pay stubs If you are self-employed or an independent contractor, attach Schedule C or Form 1099

I attest that the information I will give here is true and complete to the best of my knowledge.

I attest that I am currently employed and expect to lose wages when I take time off from work for my recovery after the donation surgery, and/or for evaluation and follow-up appointments. I understand I must notify NLDAC if I stop working, and submit new pay stubs if my wages change.

1. How often are you paid?

Weekly Every 2 weeks Twice a month Monthly Irregularly/other. Please explain: _______________

2. Do you plan to use short-term disability, paid time off, or another program to cover some of your time off work

No Yes: _______________

Note: If paid time off is available to you, you may want to use your paid time off and save NLDAC’s support for your travel costs, but NLDAC does not require that you use all of your paid time off before requesting lost wage reimbursement. If you have paid time off but choose not to use it, you will need to inform your employer.

3. For which trips would you like NLDAC to reimburse your lost wages? Only check trips that are in the future.

Evaluation (up to 3 days) Surgery and recovery (up to 4 weeks) Follow-up trips (up to 2 weeks)

4. How much of the NLDAC maximum ($6,000 to cover all expenses) would you like to dedicate to lost wages?The rest can be used for travel and dependent care. $__________

Other comments (optional): _______________

related to your organ donation? If yes, please give as much detail as possible.

Page 3 of 9

REQUEST FOR REIMBURSEMENT OF CHILD-CARE OR ELDER-CARE EXPENSES (optional)

Instructions: If you are not applying for reimbursement of child-care or elder-care expenses caused by your organ donation process, skip this page. Otherwise, please follow steps 1 and 2. Call NLDAC at (888) 870-5002 if you haveany questions.

 I attest that the information I will give here is true and complete to the best of my knowledge.

I attest that I have at least one dependent (child/disabled adult/elder) who relies on me for care, and by donating an organ I will have to pay for child-care or elder-care that I do not normally pay for. I understand NLDAC will not pay for any care my dependents already receive, like daycare while I am usually at work.

1. How many children (ages 0 – 17) will need care because of your donation?

2. On which trips would you like NLDAC to reimburse your child-care expenses? Check all that apply: Evaluation (up to 3 days) Surgery and recovery (up to 4 weeks) Follow-ups (up to 2 weeks)

3. How many disabled adults (ages 18 – 64) or elders (65+) will need care because of your donation?

4. On which trips would you like NLDAC to reimburse your elder-care (this includes people 65 and older, anddisabled adults between 18 and 64) expenses? Check all that apply:

Evaluation (up to 3 days) Surgery and recovery (up to 4 weeks) Follow-ups (up to 2 weeks)

5.

6. When will your dependents need alternate care because of your donation? Check all that apply:

During the day, Monday through Friday Evenings and/or weekends Irregularly ___________

7. How much of the NLDAC maximum ($6,000 to cover all expenses) would you like to dedicate to

Other comments (optional):

dependent care? The rest can be used for travel and lost wages. $________

Name Relationship(this person is my...)

Age

Step 1: Complete this pageStep 2: Complete and sign IRS Form W-9

List the children, disabled adults, or elders for whom you will need to arrange alternate care:

Page 4 of 9

REQUEST FOR REIMBURSEMENT OF TRAVEL EXPENSES (optional)

Instructions: To apply for help with your upcoming travel expenses, complete this page. This section is optional, and you can skip it if you would only like help with lost wages and/or dependent care.

Accompanying Person(s)

NLDAC can pay for one accompanying person to go on two round trips to the transplant center, or two people to go on one round trip.First accompanying person

Check here if same address as donor

Second accompanying person Check here if same address as donor

First name: Last name: First name: Last name:

Date of birth: Phone: Date of birth: Phone:

Street address: Street address:

City: State: Zip: City: State: Zip:

Trip(s): Evaluation only Evaluation & surgery Evaluation & follow up

Surgery only Surgery & follow up Follow up only

Trip(s): Evaluation only Evaluation & surgery Evaluation & follow up

Surgery only Surgery & follow up Follow up only

Estimated Travel Expenses

EVALUATION SURGERY FOLLOW UP

HOTEL EXPENSES Up to 2 nights Up to 14 nights Up to 1 night

Will the donor require a hotel room/lodging?

If yes, how many nights?

Will the accompanying person(s) require a separate room?

If yes, how many nights?

FOOD EXPENSES: Up to 2 nights Up to 14 nights Up to 1 night

How many nights will the donor/accompanying person(s) be away from home?

TRANSPORTATION EXPENSES

How will the donor travel to transplant center? Air, car, bus, train

If driving, how many miles will be traveled round trip?

How will the companion(s) travel to transplant center? Air, car, bus, train

If companion(s) travels in a separate car, how many miles round trip?

Will the donor need a rental car?

If yes, for how many days?

Estimate daily cost of parking at hospital, if driving or renting a car

How many days of parking do you request?

Estimate tolls (if any) $ $ $

Estimate cost if taking cabs/shuttle/Uber $ $ $

NOTE: NLDAC can approve additional trips for donor complications or related issues.

Other information about your travel plans that you would like NLDAC to consider:

Page 5 of 9

Donor Attestation Form

Transplant professionals: please retain this form in the donor’s medical record.

Instructions: Write your name in the blank near the top, read the statements and check all the boxes (except the last one, unless it applies to you), and sign your name at the bottom.

I, ____________________________________, as a live organ donor candidate, have truthfully and completely provided all the information requested in the application for reimbursement of travel and subsistence expenses and/or lost wages toward living organ donation.

The transplant center personnel have informed me of what constitutes “valuable consideration” and to the best of my understanding, I am in full compliance with Section 301 of NOTA (42 U.S.C. §274e), which stipulates, in part, that it shall be unlawful for any person to knowingly acquire, receive, or otherwise transfer any human organ for valuable consideration for use in human transplantation if the transfer affects interstate commerce.

My decision to undergo live organ donation was not motivated by the exchange of any valuable consideration.

I do not have any other information indicating that valuable consideration is being exchanged in connection with this donation procedure.

I understand that NLDAC, under Federal law, cannot provide reimbursement to any living organ donor for travel and other qualifying expenses if the donor can receive reimbursement for those expenses from any of the following sources: (1) Any state compensation program, an insurance policy, or a Federal or State health benefits program; (2) an entitythat provides health services on a prepaid basis; or (3) the recipient of the organ.

I give permission for the transplant center to share my information with the National Living Donor Assistance Center.

I acknowledge that reimbursement may be subject to federal and/or state income tax reporting. Applicant is responsible for contacting a qualified tax advisor to determine tax liability. Neither NLDAC nor other entities providing reimbursement are responsible for any tax consequences of the reimbursement program.

If this application for travel expense, lost wage, and/or dependent care reimbursement is approved, I will not request reimbursement of these costs from any other source (e.g. National Kidney Registry, Alliance for Paired Kidney Donation,Georgia Transplant Foundation, etc.).

(Only for donors whose recipient is commercially insured by UnitedHealthcare) I give permission to NLDAC to provide the information in this application to other entities, including the recipient’s health insurer, for review and potential reimbursement for travel and other qualifying expenses. The health insurer will only use or disclose the information in accordance with the applicable law.

In signing this form, I declare, under penalty of perjury under the Federal and State laws, that all the information I have provided is true, correct and complete. I further understand that Federal and State law may provide for penalties of fine and/or imprisonment or denial of the requested travel and subsistence reimbursement assistance if I do not tell the truth when applying for assistance under the live donor reimbursement program or if I conceal or fail to disclose facts regarding the information supplied in the application process.

Donor’s signature: __________________________________________________ Date: _______

Transplant center application filer’s signature: ____________________________ Date: ________

Form W-9(Rev. October 2018)Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

▶ Go to www.irs.gov/FormW9 for instructions and the latest information.

Give Form to the requester. Do not send to the IRS.

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1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes.

Individual/sole proprietor or single-member LLC

C Corporation S Corporation Partnership Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ▶

Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner.

Other (see instructions) ▶

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):

Exempt payee code (if any)

Exemption from FATCA reporting

code (if any)

(Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.) See instructions.

6 City, state, and ZIP code

Requester’s name and address (optional)

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.

Social security number

– –

orEmployer identification number

–

Part II CertificationUnder penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue

Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I amno longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.

Sign Here

Signature of U.S. person ▶ Date ▶

General InstructionsSection references are to the Internal Revenue Code unless otherwise noted.

Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9.

Purpose of FormAn individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following.

• Form 1099-INT (interest earned or paid)

• Form 1099-DIV (dividends, including those from stocks or mutualfunds)

• Form 1099-MISC (various types of income, prizes, awards, or grossproceeds)

• Form 1099-B (stock or mutual fund sales and certain othertransactions by brokers)

• Form 1099-S (proceeds from real estate transactions)

• Form 1099-K (merchant card and third party network transactions)

• Form 1098 (home mortgage interest), 1098-E (student loan interest),1098-T (tuition)

• Form 1099-C (canceled debt)

• Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a residentalien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later.

Cat. No. 10231X Form W-9 (Rev. 10-2018)

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2022 RECIPIENT APPLICATION WORKSHEETLIVING ORGAN DONATION REIMBURSEMENT PROGRAM

Page 7 of 9

First name Last name Date of birth Social Security number

Street address

City State Zip code

Sex Race Ethnicity

Male

Female

American Indian or Alaska native Native Hawaiian or other Pacific Islander

Asian White

Black

Hispanic

Not Hispanic

No

No

Are you a U.S. citizen or lawfully present resident? Yes

Have you signed the Attestation Form? (See page 8) Yes

Are you currently on dialysis? Yes No

Does your health insurance provide a travel benefit for your living donor? Yes No

If yes, what benefits are covered by your insurance (e.g. hotel, transportation, meals?)

If your health insurance provider is UnitedHealthcare, look at the bottom right of your insurance card. Does it say, “Underwritten by UnitedHealthcare?”

If yes, list the policy number: , member ID: and policy holder’s name to verify coverage.

If it says, “Administered by UnitedHealthcare Services, Inc.”, is one of the following listed below “Group Name”: UnitedHealth Group, Inc.; Optum Care, Inc.; Optum360 Services, Inc.?

INCOME INFORMATION: Combine the incomes of all members of your household. The transplant professional who files your application will confirm and record household income based on the document(s) you provide.

Yearly household income $ Persons in household #

Select the income document used to verify your household income and give a copy to your transplant professional.

Federal income tax return - most recent year (use adjusted gross income)

Pay stubs (use gross income)

W2 (use gross income)

Government assistance program (HUD, WIC, SNAP)

Medicaid eligibility

Social Security statement

Other document - (i.e. disability statement, etc.)

Instructions: NLDAC helps living organ donors with their travel expenses, lost wages, and dependent care expenses if their recipientcannot afford to do so. To apply, the donor and their recipient must complete these application worksheets, attach a copy ofa document that verifies their household income, and send their application to a transplant professional (social worker, nursecoordinator, etc.), who will submit the application to NLDAC. Do not send your application materials to NLDAC. NLDAC canonly accept applications from transplant centers. Applications must be approved before surgery, and NLDAC cannot reimburseexpenses incurred before the application is approved. Application review takes 15 business days. For more information,call NLDAC at (888) 870-5002. If this application is not approved, the recipient can provide financial assistance to the donor.While the National Organ Transplant Act (NOTA) prohibits the buying and selling of organs, it allows reasonable paymentsassociated with the expenses of travel, housing, lost wages, and dependent care incurred by the donor of a human organ.

Page 8 of 9

Recipient Attestation Form

Transplant professionals: please retain this form in the recipient candidate’s medical record.

Instructions: Write your name in the blank near the top, read the statements and check all the boxes (except the last one, unless it applies to you), and sign your name at the bottom.

I, _______________________________________________, as a transplant candidate, have truthfully and completely provided all the information requested in the application for reimbursement of travel and subsistence expenses and/or lost wages toward living organ donation.

The transplant center personnel have informed me of what constitutes “valuable consideration” and to the best of my understanding, I am in full compliance with Section 301 of NOTA (42 U.S.C. §274e), which stipulates, in part, that it shall be unlawful for any person to knowingly acquire, receive, or otherwise transfer any human organ for valuable consideration for use in human transplantation if the transfer affects interstate commerce.

My decision to undergo live organ transplantation was not motivated by the exchange of any valuable consideration.

I do not have any other information indicating that valuable consideration is being exchanged in connection with this donation procedure.

I understand that NLDAC, under Federal law, cannot provide reimbursement to any living organ donor for travel and other qualifying expenses if the donor can receive reimbursement for those expenses from any of the following sources: (1) Any state compensation program, an insurance policy, or a Federal or State health benefits program; (2) an entity that provides health services on a prepaid basis; or (3) the recipient of the organ.

I give permission for the transplant center to share my information with the National Living Donor Assistance Center.

(for UnitedHealthcare insured transplant candidates only) I give permission to NLDAC to provide the information in the application to other entities, including my health insurer, for review and potential reimbursement for travel and other qualifying expenses for my donor. The health insurer will only use or disclose this information in accordance with applicable law.

In signing this form, I declare, under penalty of perjury under the Federal and State laws, that all the information I have provided is true, correct and complete. I further understand that Federal and State law may provide for penalties of fine and/or imprisonment or denial of the requested travel and subsistence reimbursement assistance if I do not tell the truth when applying for assistance under the live donor reimbursement program or if I conceal or fail to disclose facts regarding the information supplied in the application process.

Recipient’s signature: ________________________________________________ Date: __________

Transplant center application filer’s signature: _____________________________ Date: __________

Page 9 of 9

FINANCIAL HARDSHIP WAIVER WORKSHEET – 2022

IMPORTANT: Skip this page if your household income is equal to or below the NLDAC eligibility guidelines.

NLDAC Eligibility Guidelines 350% HHS Federal Poverty Guidelines (FPG) 2022

Household size

48 Contiguous states

and D.C. Alaska Hawaii

1 $47,565 $59,465 $54,7052 $64,085 $80,115 $73,7103 $80,605 $100,765 $92,7154 $97,125 $121,415 $111,720

5 $113,645 $142,065 $130,7256 $130,165 $162,715 $149,7307 $146,685 $183,365 $168,735

8 $163,205 $204,015 $187,740

Please list monthly or one-time out-of-pocket expenses for your entire household. NLDAC will calculate annual expenses based on the information provided in the worksheet. Regular living expenses (like rent, utilities, etc.) should not be included. If you have questions, call NLDAC toll free at (888) 870-5002.

First name: Last name:

Phone: (NLDAC staff may call you to clarify information on this worksheet.)

1. $ Monthly out-of-pocket insurance premiums

2. $ Monthly out-of-pocket pharmacy co-pays before transplant

3. $ Monthly out-of-pocket pharmacy co-pays after transplant (Estimated by transplant professional)

4. $ Monthly out-of-pocket physician co-pays

5. $ Monthly out-of-pocket lab or other medical co-pays not listed above

6. $ Total hospital/medical bills owed not covered by insurance (not monthly)

7. $ Loss of income due to surgery (excluding paid time off/disability pay) - describe in *Comments

8. # miles Monthly round trip mileage for medical appointments (pre-transplant)

9. How will you travel to the transplant center for your surgery? Air Car Bus Train

10. # miles If driving, how many miles round trip to the transplant center?

11. yes/no Will you need to stay in a hotel near the transplant center after your transplant surgery?

12. # nights If you will stay in a hotel, how many nights will you stay?

13. # trips In the first 3 months after your transplant, how many trips (estimate) will you make to the hospital?

14. $ Monthly dependent care for family member not living in the household (ex. child support) - describe in *Comments

15. $ Other expenses - describe in *Comments

If loss of income, monthly dependent care for a family member not living in household, or other allowable expenses are noted above, please describe those expenses here. You may attach an additional page if desired.

*Comments:

Recipients: According to federal law, NLDAC cannot pay for a donor’s travel expenses, lost wages, or dependent care expenses if the recipient can pay those costs. If your household income is above the NLDAC guidelines but you cannot support the donor, you can request NLDAC reconsider your ability to pay by completing this worksheet, which is a financial hardship waiver request. The financial hardship waiver process requires evaluation by the transplant professional, NLDAC and the Health Resources and Services Administration using fact-specific analysis of information captured in the form below. Your allowable out-of-pocket expenses must bring your income within the income guidelines for the application to be approved. For example, if your income is $5,000 above the NLDAC eligibility guidelines, you will need to demonstrate $5,000 in allowable annual expenses.