MSNT Charitable Program Application

MSNT Charitable Program Application

Description and Information
Eligibility: Applicants Must
- Live in Missouri.
- Be deemed disabled by the Social Security Administration. Provide a copy of your Social Security Benefit Verification letter.
- Receive $15,650 or less a year in Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI).
Grant Amount
The maximum grant amount is $2,000. A treatment plan or estimate detailing the cost is required.

Grant Information
Charitable Grants are not guaranteed. Applicants are encouraged to continue to seek other funding opportunities. Applicants and Agency Representatives will receive a letter in the mail within 4-6 weeks. Grant award decisions will not be shared by phone.

Grant Payments
All payments are made by check to the provider listed on the application after the service is provided. Applicants must contact the service provider prior to submitting the application to ensure the above payment terms are acceptable.

Types of Assistance Not Provided
Grants will not be provided for (including, but not limited to):
- Services already completed or items already received,
- Vehicle expenses or purchases,
- Home repairs,
- Housing (rent, mortgage, room and board), food, utilities or cash,
- Immediate or temporary denture(s) (Complete dentures only).
Application Process
1. Complete the application.
2. Submit a copy of the applicant’s Social Security Benefit Verification Letter. Include any other forms of income received.
3. Include the estimate or treatment plan
  - Estimates must be a letter from the business including their contact information, list of item(s) needed and exact cost.
  - For home modifications, the estimate must be from a licensed contractor. Proof of home ownership or letter of approval from the landlord is required.
  - For medical needs, a treatment plan from a licensed provider is required. For hearing aids and eyeglasses, a copy of the evaluation is required.
4. For medical equipment, exercise equipment, communication devices, lift chairs, monitoring systems, and home modifications a letter of recommendation from a licensed provider stating why the item(s) are needed is required.

Grant Type and Acknowledgments
Type of Grant Requested*

Urgent (Reviewed and awarded twice a month for urgent medical and dental needs not covered by public benefits or insurance.)General (Reviewed and awarded once a month to help with other needs not covered by public benefits.)
Applicants must enter their initials indicating they understand that even if they meet the eligibility requirements and submit all required documentation, they are not guaranteed a grant.*
Enter your initials

Applicant Contact Information
Applicant Name*

First NameLast Name
Applicant Date of Birth*

MonthDayYear
Date
Applicant Address*

Street Address

Street Address Line 2

CityState

Zip Code
Applicant Phone Number*
Please enter a valid phone number.
Applicant Fax Number
Please enter a valid phone number.
Applicant Email
A copy of the application will be sent to this address.
Guardian/Conservator Name
Name of Applicant's Guardian or Conservator (If Applicable)
Guardian/Conservator Phone Number
Please enter a valid phone number.

Agency Representative Contact Information
Were you assisted by a representative of an agency in completing this form?*

YesNo
Agency Representative Name

First NameLast Name
Agency or Company Name
Agency Address

Street Address

Street Address Line 2

CityState

Zip Code
Agency Phone Number
Please enter a valid phone number.
Agency Fax Number
Please enter a valid phone number.
Agency Email Address
example@example.com

Application Checklist

Before sending in the application you must include ALL of the following documents
Social Security Benefit Verification Letter*

Cancelof
Estimate or Treatment Plan*

Cancelof
If requesting hearing aids, glasses, or home modifications check the appropriate box and upload the indicated documentation

Hearing Aids - Copy of EvaluationGlasses - Copy of EvaluationHome Modification - Proof of home ownership
Additional Documents (Copy of Evaluation, Proof of Home Ownership, Letter of Recommendation, Pay stubs, Denials from other resources)

Cancelof
How did you hear about the Charitable Grant Program?*

Signatures: Please read and complete with name and date
Applicant Name*
Date Applicant Signed*

MonthDayYear
Date
Agency Representative Name
Date Agency Representative Signed

MonthDayYear
Date
Should be Empty:

MSNT Charitable Program Application

Grant Type and Acknowledgments

Applicant Contact Information

Agency Representative Contact Information

Applicant Information

Applicant Income

Application Checklist

Signatures: Please read and complete with name and date