Step 1 of 4 25% APPLICANT INFORMATIONName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Are you a US citizen?* Yes No CHILD’S INFORMATIONChild's Name* First Last Child's Date of Birth* 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.*Max. file size: 2 MB.Attach detailed documentation of the equipment.*Max. file size: 2 MB.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?* Yes No Insurance Company:* Policy #:* Do you have Medicaid?* Yes No If yes have you filed with your insurance?* Yes No If yes have you filed with Medicaid?* Yes No If you did file with your insurance and/or Medicaid, please attach a copy of the claim.*Max. file size: 2 MB.If filed, were you denied by your insurance?* Yes No If filed, were you denied by Medicaid?* Yes No If you were denied, please attach a copy of the letter of denial.*Max. file size: 2 MB.Did you receive funding from insurance?* Yes No Did you receive funding from Medicaid?* Yes No If yes, how much?* If received, please attach documentation of the above amount(s).*Max. file size: 2 MB.Did you receive funding from Florida Human Services Authority?* Yes No Attach documentation of the amount paid or letter of denial.*Max. file size: 2 MB.Did you receive funding from any other source?* Yes No If 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?* Yes No I 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 50442
