Grant Application
for Individuals

Today's Date

Last name

First name

Birthday

Month

Day

Year

Phone

Address

County of Residence

How long have you lived at this address?

Number of people living in your home (related & unrelated)

Are you employed?

Current employer

Gross HOUSEHOLD income (monthly)

Itemized list of monthly income sources

Checking account balance

Savings account balance

List of assets (Cash, stock, bonds, retirement,...)

Monthly expenses (loans, credit cards, insurance, rent, mortgage, utilities,...)

What other funding sources have you applied to for this project?

What is your request? (amount, item, services,...)

Please give a brief explanation of your present situation and your reason for this request.

PLEASE UPLOAD:

-Medical documentation for any adaptive equipment requirements

-Tax return or form SSA-1099 for all household adults

-Proof of homeownership and homeowner's insurance

IF APPLICABLE:

Provide documentation that the project is ineligible for Medical Assistance, Waiver and/or Base Funding.

IF UNABLE TO UPLOAD THESE DOCUMENTS, EMAIL TO: DANIEL.CARD@HRFNEPA.ORG

File upload