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.Format: (000) 000-0000.
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
Date

MonthDayYear
Date
Should be Empty:

Applicant Information