The Breakthrough Fund Financial Assistance Application

The Breakthrough Fund Application

Full Application
Name

First NameLast Name
Male / Female

MaleFemaleOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Phone Number
Email
example@example.com
To be Completed by Applicant/Legal Guardian
In one paragraph, please state why you think health and wellness is important
Please make a brief statement describing why the applicant is in need of financial assistance.
To be Completed by Parent / Guardian
What is your occupation / job title?
What is spouse's occupation?
Is the applicant currently enrolled in any programs through the Office for Persons with Developmental Disabilities (OPWDD)? Learn more about OPWDD at https://opwdd.ny.gov/.

YesNo
If yes, please list the OPWDD program(s)
2023 Adjusted Gross Income
2023 Total Household Income
Number of Dependents under 18
Please list any applicable medical diagnoses
By signing this document, I agree that the information is accurate.
Parent / Guardian Name

First NameLast Name
Parent / Guardian Signature

Clear
2023 Tax Return:

Cancelof
Physician note detailing medical diagnosis:

Cancelof
Please Note: Financial assistance is not guaranteed. It will be determined based on the viability of your application. Assistance will be given based on the availability of funds and level of need.

Please write a descriptive account of why the applicant is in need of financial assistance.

This application is confidential. The information on the form will not be disseminated.

We will notify applicants of the award amount within 2/4 weeks.

Need is the most important priority for the Financial Assistance Program.
Should be Empty:

The Breakthrough Fund Application

To be Completed by Applicant/Legal Guardian