Individual Grant Application

Applicant Information
Applicant's Name*

First NameLast Name
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Contact Person*
Contact Person's Relationship to Applicant*
How Many in Household?*
Please List Household Members' Name, Age, and Relationship, including Applicant.*
Household Income*

Please Attach the Following Documents
Proof of Autism Diagnosis (examples include a letter from a physician, IEP showing classification, or a neuropsychiatric evaluation.)*

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Proof of Income (a copy of your most recent Federal Income Tax Return (first 2 pages only), W-2, paystubs, SSA award letter, or other documentation)*

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Letter of Justification from Appropriate Professional (ex. a request for sensory equipment must include a letter from an OT)*

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Verification
Please verify that you are human*
I verify that all information provided in this application is true and accurate. I understand that any falsification would disqualify this application.
Signature*

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Date*

MonthDayYear
Date
Should be Empty:

Applicant Information