HAND Grant Application    Please Print and then mail Application

CHILD  _______________________________ Age 

Name: _________________ Age:__Birthdate: ____

MOTHER

Mother’s Name:______________________________  

Marital Status: ____ Telephone: ________________

E-mail Address: ______________________________

Street/City/Zip: ______________________________

Employer:__________________  Telephone: __________________ 

Employer Address:________________________________________

 

FATHER

Father’s Name:___________________________________________  

Marital Status: _______       Telephone: _____________________

E-mail Address:__________________________________________

Street/City/Zip:__________________________________________

Employer:___________________   Telephone: ________________

Employer Address:________________________________________

 

Number and ages of other dependent children:___________________________

 Diagnosis of Disability:

_______________________________________________________

_______________________________________________________

Outline of funding requested:

$______________ (Be specific and include all costs and attach any applicable bills.)

_______________________________________________________

_______________________________________________________

_______________________________________________________

 

Have you ever received funding from other organizations?  yes____ no____

 

Name of other agencies or services also contacted for funding:
Please indicate which have been contacted and the amount requested/received.

_______________________________________________________

_______________________________________________________

 

SUPPLEMENTAL SECURITY INCOME (SSI)  $_________

 

Personal Statement of Combined Income for Parents/Guardians :

 

COMBINED INCOME -  MONTHLY 

 

Salary:

$___________

Bonuses and Commissions:

$___________

Alimony/Child Support:

$___________

Real Estate Income:

$___________

All Other Income:

$___________

TOTAL INCOME:

$___________

 

The above information is freely given to expedite this grant request.

 

PARENT/GUARDIAN SIGNATURE:____________________ DATE:____________

 

Mail completed application, documentation confirming child’s diagnosis (i.e., school eval, or doctor’s note), any applicable bills and previous year’s IRS return to:  

HAND

2464 Headhouse Sq S.

Bensalem PA 19020

This application cannot be considered until this form is completed, signed, and all supporting documents are received.  The information included in this application is confidential and for HAND use only.  Please keep a copy for your records.