Application for New Ideas Funds

Application for New Ideas Funds

Special Needs Foundation of Des Moines County. 829 Harrison Ave. Burlington, IA 52601 Phone 319-752-8222
New Ideas Committee Criteria
1. Must be a resident of Des Moines County.
2. Items or services purchased are for individuals or groups and become their property
3. Items or services should improve or enhance the quality of life for disabled persons and their familes.
4. To create an awareness of disabilities in schools and communites in Des Moines County
5. Funds must be spent within 6 months of receipt on the equipment or service specified below
Application for New Ideas Funds:
Date:*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Recipients Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Service/ Equipment Needed:*
Where to Purchase:*
Costs (Including Shipping, etc.)*
Please Attach a Formal Letter of Request to This Application:*

Cancelof
Signature (for request):*

Powered by Jotform SignClear
This Application has been approved by two (2) New Ideas Committee Member (to be completed by committee):

1.

2.
Should be Empty: