Helping Way Fund - Accessibility Funding Application Form
Provided through the R. Vance Milligan Memorial Fund, the Accessibility Fund supports persons with spinal cord injuries anywhere in Alberta with a significant need for support and who is experiencing financial hardship. Applications are received and reviewed twice per year. Funds are administered by The Alberta Paraplegic Foundation in partnership with Spinal Cord Injury Alberta.
Applicant Information
This is the contact information for the applicant only. Please fill out all sections.
Name of Applicant
First Name
Last Name
Applicant's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Applicant's Phone Number
Please enter a valid phone number.
Applicant's Email
example@example.com
Please describe your disability.
Describe the Need
When filling out the information below, please be concise but ensure that there is enough information provided to express the needs to support the applicant.
Please describe the item(s) or service you are requesting support for. If there are multiple items, please outline them using a numbered list.
What is the total expense of the item(s) or service you described above?
What is the total amount of funding that you are requesting?
Please attach estimate(s) relevant to the item(s) or service that you are requesting support for. To have multiple items considered, please upload a quote for each.
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Please describe how this item or service will impact or enhance your independence, self-reliance and/or full community participation.
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Financial Information
Please provide as much information as possible to help us understand your current income.
What is your net annual income from all sources?
Please attach a copy of your most recent Notice of Assessment.
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Are you currently employed?
Yes
No
If you replied yes to the previous question, please provide proof of employment income (e.g. letter of employment, copy of most recent pay stub.)
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Do you currently receive AISH?
Yes
No
Do you receive equipment support through AADL?
Yes
No
Please provide detail about equipment support you receive through AADL.
Do you have extended health benefits insurance?
Yes
No
If you replied yes to the above question, please provide details about your insurance plan.
Do you receive WCB?
Yes
No
Do you have a spouse/common law partner with income?
Yes
No
If you do have a spouse/common law partner with income, please provide their annual gross income below.
Do you have any dependents?
Yes
No
If you have any dependents, please include their age(s) here. If they are over the age of 18, please provide more information (e.g. are they a student, or do they have a disability?)
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Living Expenses
In this section, please provide as much detail as possible to help us understand your living expenses.
If you have a monthly budget, please upload it here. If not, please proceed to the next set of questions.
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What is your monthly rent/mortgage payment?
What is your monthly car payment(s)?
What is your monthly Insurance expense?
What is your monthly utilities expense?
What is your monthly credit card payment?
What is your monthly medical expense?
What is your monthly payment for other loan(s)?
Please include any other expenses here:
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Other Information
These questions will help us understand your need and other potential funding sources to support your need.
Have you applied for funding for this request through other funding sources?
Yes
No
If you replied yes to the above question, please provide details including how much you've requested and the date you should receive a response. If you have already received funding, please indicate the amount received.
If you are not successful with this application, will you still proceed with purchasing the item or using the service?
Yes
No
If you are not successful with this application, what alternative or back up plan will be put in place to meet this need?
Have you previously applied for Accessible Funding through the Helping Way Fund?
Yes
No
If you answered yes to the above question, please indicate the year you applied.
Please add any relevant information for this application that has not already been covered.
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Authorization and Consent
This section is where you provide authorization and consent to this application being submitted and for SCI-AB to receive the information for assessment.
If I am a successful applicant, I am willing to be interviewed, provide photos and/or a written statement about how the receipt of funds has assisted me and my connection to my community.
Yes
No
If you answered no to the above question, please explain.
I certify that the information included in this application is true and correct. I authorize Spinal Cord Injury Alberta and The Alberta Paraplegic Foundation to contact employers, institutions and others as listed on this application to validate information provided.
Yes
No
If you answered no to the above question, please explain.
If your request is approved, please let us know who the funding will be provided to. Please provide the name of the Company, Contact Person, Full Mailing Address, Phone Number and Email.
Please insert the date this application was completed.
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Month
-
Day
Year
Date
Please insert the name of the person who completed this application form (if different from applicant)
First Name
Last Name
Please insert the email of the person who completed this application form (if different from applicant).
example@example.com
Please insert the phone number of the person who completed this application form (if different from the applicant).
Please enter a valid phone number.
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