FINANCIAL ASSISTANCE REQUEST

Client: Please provide information in blank boxes, check boxes, and verify any other printed information on this form.
FINANCIAL ASSISTANCE REQUEST
Date of Request:

MonthDayYear
Date
Amount Requested:
Date Approved:

MonthDayYear
Date
Amount Approved:
Description of Needed Item(s):
Special Circumstances:
Client:
County:
Address:
Diagnosis:
City, ST Zip:
Phone(s):
Gender:
DOB:

MonthDayYear
Date
Email:
example@example.com
Contact Name:
Organization:
Parent/Guardian:
Relationship:
Relationship:
Address:
Address:
City, ST, Zip
City, ST, Zip
Phone(s)
Phone(s)
Please enter a valid phone number.
Email:
example@example.com
Email:
example@example.com
Gender:
Gross Household Monthly Income:
Number of Persons in Home:

Rows	Applied	Receiving	Person(s) Covered
SSI/SSDI
Medicaid
Medicare
Sooner Start (up to age 3)
In Home Support Waiver (MR 3 and up)
Advantage Waiver (ages 21+)
Community Waiver (MR-Emergency)
Family Support Payment (Birth - 18))
Private Insurance
Respite Care Voucher
Disabled Child Program (0-18 Medicaid/SSI)
TEFRA

The information provided in this application is true and correct to the best of my knowledge. I have to the best of my ability contacted all other known funding sources. I agree to return the aforementioned equipment back to Cerebral Palsy of Oklahoma, Inc., dba Ability Connection Oklahoma if there comes a time I no longer require its use.
Signature
Date

MonthDayYear
Date
Printed Name
ONLY ORIGINAL APPLICATIONS ACCEPTED - DO NOT DUPLICATE