Instructions: Please print form and fill out all the blanks that apply to your request. Attach copies of original quotations, order forms or any other information that might help us to complete your request. The Board shall review each request as an individual request unique to each family as an individual unit.

DATE:____________________ AMOUNT REQUESTING:_________________

FAMILY NAME:___________________________________________________________________________

ENROLLEE NAME: ____________________________________________ DOB: ______________________

ADDRESS: _______________________________________________________________________________

PHONE NUMBER: ________________________________________________________________________

TYPE OF SERVICE BEING REQUESTED:

____Respite- Dates of Service: ___________In home ________# hours - Out of home ________# hours

____Purchase or Lease of Adaptive Equipment (Requires professional recommendation)

____Home Modifications

____Special Diets (Requires professional recommendation)

____Counseling, Training and Education for Family

____Summer Programs

____Adaptation/Modification Grant (Includes Transportation Grant/Fencing)

____Therapy Training Grant

____Other (please include specific explanations and professional recommendations)

Is this an emergency request? (Circle One) YES NO

If yes, state nature.

Please describe the item or service you are requesting assistance with. Include cost, quotes you have received and any necessary specifications.

If there is any other information that you feel would assist us in making our decision please use the space below.

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Make check/voucher payable to: ______________________________ SS# of this person ________________

Send check/voucher to:

Address: _________________________________________________________________________________

City: _____________________________________ State: _____________ Zip: ________________________

Signature of Family: ____________________________________________ Date: ______________________

__________________________________________________________________________________________

*Fill out this portion ONLY IF REQUESTING RESPITE SERVICES

I assure that my family selected provider meets the needs of my family. I absolve the Erie Co. Board and The Arc of Erie Co. of any liability for this provider.

Name of Provider ___________________________________________________________________________

Provider Address____________________________________________________________________________

City:__________________________________________State:__________________Zip:__________________

__________________________________________________________________________________________

Please send all requests to:

The Arc of Erie County
Attn: Family Directed Resources (FDR)
4405 Galloway Road
Sandusky, OH 44870

Requests will be honored if funds are available and request is consistent with the definition of approved services. Payments will be drawn from the calendar year in which services were rendered. To ensure payment, the family must honor requested deadlines for turning in completed requests. Original invoices, quotes, receipts are required in order to process payments. Faxes and copies will not be accepted. You will be notified within 30 days if your request was approved or denied.

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Service Code: AE, HM, R, SD, CTE, O, SP, AMG, TTG

FDR Portion $_________________________ Family Portion $_____________________

__________________________________________________________ _____________________________
FDR Coordinator ____Approved ____Denied

__________________________________________________________ _____________________________
____Approved ____Denied