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The Kaleidoscope Center 4405 Galloway Road Sandusky, OH 44870 419-625-9677 1-800-491-4566 Fax 419-625-3448 |
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Links Section
THE ARC OF THE UNITED STATES THE ARC OF OHIO THE UNITED WAY AIRS 2-1-1 UNITED WAY OF ERIE COUNTY ERIE COUNTY BOARD OF MR/DD DOUBLE S INDUSTRIES SPECIAL OLYMPICS OHIO ERIE COUNTY CARE-A-VAN MY VOICE MY CHOICE
Aid To Individuals
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The Aid to Individuals program was first initiated by The Arc of Erie County's Board of Directors. In years part the program has existed to provide funding to individuals with disabilities who may be unable to secure funding for certain needs from other sources. Aid to Individuals has been used to help pay for adaptive equipment, environmental modifications, education or recreation and social experiences, and other special needs specific to each individual.
Instructions: We consider completed requests at each board meeting, the fourth Monday of the month. Please fill out all the blanks that apply to your request. Attach copies of business quotations and correspondence with other funding sources.
DATE:_____________AMOUNT REQUESTING________________________
NAME OF APPLICANT:_________________________________________
SUBMITTED BY: _____________________________________________
FOR WHOM IS THE REQUEST BEING MADE:________________________
THEIR AGE: _____________
ADDRESS
PHONE NUMBER:_______________________________
HAVE YOU RECEIVED AID TO INDIVIDUAL ASSISTANCE WITHIN THE LAST 12 MONTHS?____________________
HAVE YOU RECEIVED AID TO INDIVIDUAL ASSISTANCE WITHIN THE LAST 6 MONTHS?_____________________
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Are you presently enrolled in the Family Directed Resource Program? YES NO
Is this an emergency request? (circle one) YES NO
If yes, state nature. If no, answer the following that apply
Please describe the item or service you are requesting assistance with. Include cost, quotes you have received, and any necessary specifications. If utility assistance, furnish copy of notice.
How will you continue to support this need in future months if necessary?
Please list other funding sources you have or will be contacting and the dollar amount of any assistance given.
How much of the total cost do you already have covered? Please list amount and source.
In the last year to whom have you applied for specific assistance.
HOUSEHOLD MEMBERS' INFORMATION:
NAME AGE RELATIONSHIP PLACE OF EMPLOYMENT
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Yearly family income from all sources: (Check one)
0-10,000 ____________
10,000-20,000 _____________
20,000-30,000 _____________
30,000-40,000 _____________
40,000-50,000 _____________
over 50,000 _______________
Do you rent or own your home? (for structural or modification assistance)
Medical expenses not covered by insurance.
Do you have a Medicaid card (Circle One) YES NO
Other special expenses not covered by outside funding sources. Please list type of expense and amounts (example: ramp-$400 our contribution, tutoring-$200 our expense).
If there is any other information that you feel would assist us in making our decision please use the space below.
Release of information to The Arc Board
Signature of Applicant: __________________________________
