Financial Assistance Grant Application Step 1 of 4 25% APPLICANT INFORMATIONName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone*Email* Are you a US citizen?*YesNoCHILD’S INFORMATIONChild's Name* First Last Child's Date of Birth* Date Format: MM slash DD slash YYYY Tell us about your child's disability/diagnosis.* What equipment/assistance are you requesting?Attach a written statement from your healthcare provider describing the need for the requested equipment.*Attach detailed documentation of the equipment.*Include below the requested amount, a personal statement describing why the equipment is needed, how it will make a positive difference, and any other information you would like considered.* SOURCES OF FUNDING AND AMOUNTSDo you have private insurance?*YesNoInsurance Company:*Policy #:*Do you have Medicaid?*YesNoIf yes have you filed with your insurance?*YesNoIf yes have you filed with Medicaid?*YesNoIf you did file with your insurance and/or Medicaid, please attach a copy of the claim.*If filed, were you denied by your insurance?*YesNoIf filed, were you denied by Medicaid?*YesNoIf you were denied, please attach a copy of the letter of denial.*Did you receive funding from insurance?*YesNoDid you receive funding from Medicaid?*YesNoIf yes, how much?* If received, please attach documentation of the above amount(s).*Did you receive funding from Florida Human Services Authority?*YesNoAttach documentation of the amount paid or letter of denial.*Did you receive funding from any other source?*YesNoIf yes, please list the source(s).*If yes, please list the amount(s)* INCOME INFORMATIONWhat is your total annual income? (Please include employment, child support, food stamps, SSI, etc)* I certify that my answers are true and complete to the best of my knowledge. [initial below]*I understand that false or incomplete information on the application will result in denial of assistance. [initial below]*Do you grant ACCESS permission to use the name and likeness of your child in publicity and materials?*YesNoI grant ACCESS permission to use the name and likeness of my child in publicity and materials. [initial below]*The application must be fully complete in order to be considered, and will remain valid for two years from the date of the application
