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 (copy of Benefit Verification Letter required)
- Receive $15,960 or less per year in Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI).
GRANT DETAILS
- Maximum grant: $2,000
- Treatment plan or cost estimate required
- Grants are not guaranteed
- Decisions mailed within 4–6 weeks (no phone notifications)
PAYMENT INFORMATION
- Payment made by check directly to the service provider
- Issued after services are completed
- Applicants must confirm provider accepts these terms before applying
NOT COVERED
- Services or items already received
- Vehicle purchases, repairs or fuel
- Home repairs
- Housing, food, utilities, or cash assistance
- Immediate or temporary dentures (complete dentures only)
APPLICATION PROCESS
1. Complete the Application.
2. Submit Income Verification - Provide a copy of the applicant’s Social Security Benefit Verification Letter. Include documentation for any additional income received.
3. Provide an Estimate or Treatment Plan
  - Estimates must be submitted as a formal letter from the business, including:
    
    Contact information
    
    Itemized list of required items
    
    Exact cost of each item
  - Home Modifications
    
    Estimates must be provided by a licensed contractor.
    
    Proof of homeownership or a letter of approval from the landlord is required.
  - Medical Needs
    
    A treatment plan from a licensed provider is required.
    
    For hearing aids and eyeglasses, include a copy of the evaluation.
  - Medical Equipment, Exercise Equipment, Communication Devices, Lift Chairs, and Monitoring Systems - A letter of recommendation from a licensed provider is required, explaining why the item(s) are needed.

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 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