Funding Request Form

Apply for financial resources to help your family with autism related expenses

Through the generous contributions of community members throughout Cortland and contiguous counties Puzzle Solvers, Inc. is able to donate back to individuals, families, schools and provider agencies to improve the quality of life for people impacted by ASD. Currently, requests are restricted to Cortland County residents and can include, but are not limited to, communication devices, complimentary therapies, adaptive toys, ABA therapy, travel expenses to doctor appointments, and more.

FUNDING REQUEST FORM

MISSION: to provide resources, increase awareness and raise funds for families and individuals impacted by autism spectrum disorder so they can enhance their quality of life.

Through the generous contributions of community members throughout Cortland and contiguous counties Puzzle Solvers, Inc. is able to donate back to individuals, families, schools and provider agencies to improve the quality of life for people impacted by ASD. Currently, requests are restricted to Cortland County residents and can include, but are not limited to, communication devices, complimentary therapies (such as special diets, nutritional supplements, holistic therapy, etc.), adaptive toys, ABA therapy, travel expenses to doctor appointments, and more.

GENERAL INFORMATION - You may get help completing this information if necessary. If completing this form is a barrier, we will honor your request in any form – text to talk, auditory, etc.

* Indicates required field

Person Requesting Funds *

First

Last

Relationship to person with Autism Spectrum Disorder (Autism, Aspergers, PDD-NOS, Rett’s, Childhood Disintegrative Disorder) *

Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email Address *

Does the person receive assistance from other agencies/programs? *

Yes No

If so, state agency name, program and amount/hours received. (Assistance from other agencies does not exclude you from asking for assistance from us).

If yes, date of previous request *

Agency(s) name *

Amount *

Amount requested *

Can we refer this person to the appropriate services in Cortland County? *

Yes No

In the space below please tell us about your story, what you would use the money for and why you feel a donation to you could help your family *

PLEASE ENCLOSE A LETTER OR DOCUMENTATION CONFIRMING AN ASD DIAGNOSIS OR IF NO DIAGNOSIS HAS BEEN CONFIRMED INCLUDE A LETTER DESCRIBING YOUR ATTEMPTS TO DIAGNOSE.

Include if necessary:

Financial support you have received from other agencies
Any additional circumstances that impact your request
Programs or services you current receive or have previously received

Letter/Documentation Upload *

Max file size: 20MB

Submit

Note: If funding allocation is approved, you may be asked to submit receipts showing appropriate use of the funds.

DOWNLOAD FORM

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funding_request_form.doc
File Size:	93 kb
File Type:	doc

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