Family Mental Health Care Fund Family Attestation Form

The Community Foundation of the Texas Hill Country

Family Mental Health Care Fund Attestation Form
If you are a person seeking support through the Family Mental Health Care Fund established by the Community Foundation of the Texas Hill Country, please complete the information below. If you have questions about the Fund, please use this link for answers to Frequently Asked Questions (FAQ).
Contact Information for the Person Seeking Supports
Full Legal Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If the person is under age 18, please provide the name of their parent or legal guardian.

First NameLast Name
Family Information
Full Name of the Family Member Lost in the July 4 Floods*

First NameLast Name
Attestation Statement

To be completed by the person receiving reimbursement or their parent/legal guardian if the person is under age 18.
I am a family member of a person who lost their life in the Texas Hill Country floods on July 4, 2025.I am applying for reimbursement of out-of-pocket behavioral health expenses (co-pays, deductibles, or co-insurance) incurred between July 4, 2025, and March 31, 2026.I have read the answers to the Frequently Asked Questions (FAQ) and understand the purpose and limitations of the Fund.I affirm that the information provided in this attestation is complete and accurate to the best of my knowledge and that all listed individuals consent to inclusion for eligibility purposes.I agree to notify the Fund if any family information changes during the eligibility period.I will not provide any personal information about myself or family other than the information that has been expressly requested, and I understand that if any personal information is provided that has not been expressly requested, it will be disregarded and permanently destroyed/deleted.
Signature of Applicant*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Should be Empty:

The Community Foundation of the Texas Hill Country

Contact Information for the Person Seeking Supports

Family Information

Attestation Statement