Community Fund Management Foundation

Transcription

1 Community Fund Management Foundation Grant Application for Individual This Application is for: (check one) Accessibility Grant Education, Therapy, and Services Grant Hardship Grant for Former CFMF Trust Beneficiaries Grant Applicant This Application is for the following individual, who is an Ohio resident with a disability: Name: Address: City: State: Zip: Phone: SSN: Date of Birth: Fax: Has a CFMF Individual Grant Application been submitted previously for this Applicant? NO YES If YES, what was the outcome of the previous application? Denied Approved $ Amount Awarded Please Note: While a qualifying individual may submit multiple grant applications, there is a lifetime maximum of $5,000. The combined value of all CFMF grants awarded to the same individual shall not exceed $5,000. Information Regarding Grant Applicant 1. Please describe the Grant Applicant s disability: 2. Is the Grant Applicant a current or former beneficiary of a CFMF Trust? NO YES If YES, please provide the Trust Agreement Number: 3. Does the Grant Applicant have any pending applications for government benefits? NO YES If YES, what applications are pending? Grant Application for Individual Page 1 of 6

2 Submission Applicant This Application is being submitted by the following person: (check one) Grant Applicant listed above (It is not necessary to complete or initial the following section) Parent / Immediate Family Member of Grant Applicant (Please complete and initial the following section) Guardian for Grant Applicant (Please complete and initial the following section) CFMF Designated Advocate for Grant Applicant applies only to Applicant who is the Beneficiary of a CFMF Trust (Please complete and initial the following section) Name: Address: City: State: Zip: Phone: Relationship to Grant Applicant: Please initial the line below to indicate your agreement and compliance with the following statement: As the Submission Applicant, I certify that I have authority to apply for a CFMF grant on behalf of the Grant Applicant, and I am completing this application in good faith. Fax: Information Regarding Grant Request 1. Amount Requested: $ (Lifetime Maximum: $5,000.00) 2. Grant Check Information: Grant checks will usually be issued to vendors and service providers only, not to individual grant applicants. If this grant is awarded, the check should be made payable to the following Vendor or Service Provider (attach additional pages if necessary): Business Name: Address: City: State: Zip: Phone: Fax: Grant Application for Individual Page 2 of 6

3 Please note the following regarding issuance of grant checks: Checks will be issued to no more than two (2) vendors or service providers per grant application. Grant checks can be issued to online vendors only if the vendor accepts third-party checks. Some online vendors do not. If listing an online vendor in this application, please first contact the vendor to ensure they can accept a third-party check. If a grant check needs to be payable to someone other than a vendor or service provider, please explain on the lines below. However, please note that CFMF may not be able to honor all requests, because CFMF will not make grant checks directly payable to SSI recipients or other individuals whose public benefits eligibility could be affected by receiving a direct grant payment. 3. Detailed explanation of reason for Application. Please include the following information (attach additional pages if necessary): a. Reasons for grant request, including why grant is needed and how Applicant will benefit from the item/service to be funded. b. Description of any other financial resources available to Applicant to pay for the item/service. c. If grant award will not fully cover the cost of the item/service, how Applicant plans to pay the balance. Grant Application for Individual Page 3 of 6

4 4. Documentation of amount requested. Please attach detailed documentation to support the dollar amount requested, such as an estimate, invoice, bill, or receipt. List of attached documents: a. b. c. 5. Documentation of disability. Please attach documentation to show that Grant Applicant is an individual with a disability. If the Applicant receives SSI or SSDI, please attach a copy of an SSI or SSDI benefits statement dated within the past 12 months. Otherwise, please attach the first page of an IEP, ISP, or IFSP dated within the past 12 months. List of attached documents: a. b. c. 6. Verification of financial need. For the application to be considered, the statement below must be signed and dated by the Submission Applicant and the income checklist below must be fully completed. Grant Applicant Income Checklist Wages/Earnings... No Yes $ Monthly If Yes, Employer: Social Security Administration (SSA) Benefits (retirement)... Address: City: No Yes $ Monthly Supplemental Security Income (SSI) Benefits... No Yes $ Monthly Social Security Disability (SSD) Benefits... No Yes $ Monthly Social Security Spouse s Benefits... No Yes $ Monthly Social Security Children s Benefits... No Yes $ Monthly Ohio Works First (OWF, formerly ADC)... No Yes $ Monthly Temporary Assistance for Needy Families (TANF)... Prevention, Retention and Contingency Program (PRC)... No Yes $ Monthly No Yes $ Monthly Disability Assistance (DA)... No Yes $ Monthly Grant Application for Individual Page 4 of 6

5 Veterans Administration (VA) Benefits... No Yes $ Monthly Railroad Retirement Benefits... No Yes $ Monthly Black Lung Benefits... No Yes $ Monthly Child Support... No Yes $ Monthly Other Benefits:... No Yes $ Monthly The Grant Applicant does not receive wages or government benefits. Other Resources Food Assistance... No Yes $ Monthly Other... No Yes $ Monthly Medical Coverage Medicaid... No Yes Do you have a spend down?... Do you receive Waiver services?... No No Yes, If YES, amount $ Yes If you receive a Waiver, please provide type: Medicare... No Yes Other (private, third-party insurance)... No Yes Please sign and date below to indicate your agreement and compliance with the following statement: Without a grant from CFMF, the applicant would be unable to purchase the item or service for which funding is requested. I certify that the income checklist above contains accurate and complete information about all income the Grant Applicant receives. Printed Name: Signature: Date: Grant Application for Individual Page 5 of 6

6 By signing my name below, I understand and agree to the following: All information provided in this Grant Application is accurate. CFMF Individual Grants are limited to a lifetime total of $5,000 per Grant Applicant. To evaluate this grant request, CFMF will rely solely on the information provided by me in this Application and in any written supplement to this Application that I submit. If this Application remains incomplete on the last day of the quarter in which I submitted it, it will be returned to me and will not be considered for approval. CFMF is not responsible if it approves this grant request and the receipt of funds causes the recipient or his/her family to lose eligibility for government benefits or otherwise be penalized or harmed by the grant approval. The person submitting this Application is responsible for understanding the ramifications of approval. The Grant Applicant and Submission Applicant will cooperate with CFMF and provide requested documentation to confirm that the funds are being used for the requested and intended purpose, should this Application be approved. In the event this Application is approved, the Grant Applicant agrees that CFMF may disclose the approval, amount, and reason for the grant, but not the Applicant s name, address, or personal identification information, on CFMF s website, annual report, or through other written or electronic means in CFMF s sole discretion. Signature of Submission Applicant Date Printed Name of Submission Applicant Completed applications with supporting documents should be sent to CFMF s Administrative office via mail or fax: Attn: Grants Community Fund Management Foundation Jefferson Park, Suite 102 Middleburg Heights, OH Phone: (216) Fax: (216) Grant Application for Individual Page 6 of 6