Individual Application

Individual Application for Funding
Guidelines for Applicants

This application and all supporting documentation must be completed and submitted in its entirety in order to be considered for funding. You may be contacted by The Lellow Foundation if additional information is needed.

If you require assistance filling out this application or would like to request the application in a lnaguage other than English, please contact The Lellow Foundation directly.

The Lellow Foundation will consider applications of those who demonstrate a significant financial need and an absolute inability to cover expenses for specific services or items which will support the child in need. Submissions will be reviewed in accordance with approval criteria established by The Lellow Foundation Board of Directors.

The beneficiary of services funded by The Lellow Foundation must be a child with special needs.
Personal Information of Applicant and Child
Parent(s) or Legal Guardian(s) *

First Name Last Name
First Name Last Name
Parent or Guardian Social Security Number *
Parent or Guardian Social Security Number *
Submit Proof of Identity for Parent(s) or Legal Guardian(s) *

Passport Valid Driver License
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Cancel of
Child's Name *

First Name Last Name
Child's Birthdate *

Month Day Year
Child's Social Security Number *
Child's Documentation *

Birth Certificate Legal Guardianship Paperwork
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Cancel of
Marital Status: *

Single Married Other
E-mail *
example@example.com
Phone *

Area Code Phone Number

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Employment Summary
Employment Status of Applicant *

Full-time Part-time Unemployed Housewife
Employer *
Employment Status of Spouse *

Full-time Part-time Unemployed Housewife
Employer *
Household Monthly Income
Monthly Household Income, including any Government Assistance *
Income
Indicate all factors included in Monthly Income stated above. *

Alimony Unemployment Child Support Spouse Income Worker's Comp Trust Fund
Household Monthly Expenses
Monthly rent/mortgage *
Expenses
Utilities (gas, electric) *
Expenses
TV/Cable/Phone *
Expenses
Vehicle Payment(s) *
Expenses
Insurance *
Expenses
Other *
Expenses
Validation of Financial Need

Please upload supporting documentation or send by mail to 8001 Underwood Drive Missouri City, TX 77459
Proof of Income *

Most recent Income tax return
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Cancel of
Government Assistance

Medicaid Letter Food Stamps Letter
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Cancel of
Validation of Special Need of Child

Please upload supporting documentation or send by mail to 8001 Underwood Drive Missouri City, TX 77459
One or both of the following required to indicate child's medical diagnosis and/or special education eligibility *

ARD paperwork Medical Paperwork
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Cancel of
Description of Funding Request
Describe your child's Special Needs *
Describe the service or item for which you are requesting funding *
Describe how this service or item will impact or improve your child's life *
Additional information
I give my consent to The Lellow Foundation to obtain and share information from any source to verify the statements I have made and to determine funding approval. *

YES
I attest under penalty of perjury that the answers given are true and correct to the best of my knowledge *

YES
Information provided to The Lellow Foundation will be used for the sole purpose of determining financial and special need for those requesting funding.
Should be Empty:

Individual Application for Funding

Personal Information of Applicant and Child

Employment Summary

Household Monthly Income

Household Monthly Expenses

Validation of Financial Need

Validation of Special Need of Child

Description of Funding Request