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Individual Grant Application

Complete this application form if you are applying for assistance for an individual with I/DD.

Full name of individual(s) to benefit from the request *

Date by which funds are needed *

$ Amount Requested *

Is this an Emergency Request? *

Yes

Type of Request *

One-time

Ongoing

Nature of Request *

Utility Payment(s)

Medical Expense(s)

Other

For how long will funds be needed? *

Describe the need for assistance *

Utility Payments

Have payment plans been considered? *

Yes

List other utility assistance programs that have been approached *

Medical Expenses

Does the individual have OHP? *

Yes

Has the individual applied for OHP? *

Yes

Does the individual have Medicare? *

Yes

Does the individual have private health coverage? *

Yes

Have reduced rate prescription cards or manufacturer free medication programs been applied for? *

Yes

Other Resources

The Arc of Tillamook County has limited resources and prefers to be the last source of support. Tell us about other sources of support already approached and the outcome: *

Does the individual (or family) have resources to contribute to the need? *

Yes

Describe the level of support provided for this need *

Describe the plan to meet this need in the future *

If this request is denied, will it impact the well-being of this individual? *

Yes

If denied, describe back up plans you have to meet the need *

Administration of Funds

Name of Individual/party that will administer funding/assistance and oversight to assure funds are used appropriately *

How will funding support be administered? *

Requested By

Contact information for the person submitting this request

Full Name *

Email Address *

Phone Number *

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