2024 Deepwood Foundation Individual Grant Request

Community Assistance Individual Application Funding for this application applies to all Deepwood Foundation Programs - i.e. The Deepwood Run, Lantern Fund, Schindler Fund, and Lake County Parent Group Applications must be complete to be considered. Incomplete applications will be returned without consideration. A complete application must include: 1. All questions on this form completely answered (when applicable). 2. Documentation of diagnosis from a doctor or IEP. A therapist recommendation is required for therapies and equipment. 3. Copy of the applicant/family’s Financial Verification Form including: 2023 Federal Income Tax Return with copies of W-2s attached; and verification of Social Security or SSI for parents and individual, Child Support, Alimony, Pension, ADC, Self-employment or Unemployment (information will be destroyed upon the conclusion of the grant). 4. A copy of the cost of requested items/services such as 2 written vendor cost quote including shipping and handling costs, a catalog page, a camp fee schedule, or a service fee schedule. Returned applications can be resubmitted once complete. Completed applications will be considered in February, May, August and November and must be returned by the 1st of that month.

Age of Person with DD:

Email

Diagnosis:

Please describe the applicant's diagnosis. A copy of a formal medical diagnosis or current IEP is required and must to be sent in with your application's supporting documents. Instructions to do this are at the bottom of this application.

Contact Email:

School or Activity Program in Which the Person is Enrolled:

Number of People in Family:

Name of Service and Support Administrator:

Assistance Information

If "other" is chosen above, please explain:

Please note: Deepwood Foundation cannot reimburse for past expenses.

Grant Request Information

Purpose of Grant:

Describe in detail.

Amount of Grant Request:

$

Please include a vendor-written quote that includes shipping and handling with your supporting documents.

If this application is not for the total cost, what other sources are being used to fund this need?

If you checked any of the boxes in the above question, on what date(s) did you request assistance and what is the status of the request(s)?

What other funds have been sought and what were the results?

Please list any other unusual expenses the family has incurred for this reason.

If you answered "yes" above, please provide the date the grant was received, the amount of the grant, and the reason for the grant.

Attestation

Application Assistance Information

Association:

Email:

Financial Verification for Assistance

Financial assistance from the Deepwood Foundation is available based on total family income and needs and is available for Camp, Respite, Adaptive Equipment, Emergency Needs and other expenses incurred on behalf of a person with developmental disabilities living in Lake County, Ohio. If the individual is age 18 or older, only the individual income is required. The Community Assistance Program is operated by The Deepwood Foundation; it is the policy of DWF that acceptance into, and participation in a program of the Agency shall be made regardless of race, ethnicity, age, color, religion, sex, national origin, sexual orientation, or disability. Assistance CANNOT be awarded unless verification of total family income (or individual income if the applicant is over 18) is enclosed with this request. Please provide a copy of the following: 2023 Federal Income Tax Return (copy of first page only) and copies of W-2’s attached Copies of Social Security or SSI for parents and individual, Child Support, Alimony, Pension, ADC, Self-employment or Unemployment

Please describe the recipient's source of income, amount of income, and how often it is received. If applicant recipient is a minor, please include the income of their parent(s) or guardian(s).

Example: "Mom, employed, $600 weekly" or "Individual/applicant, SSDI, $890 monthly"

Supporting Documentation Requirements

Applications must be accompanied by supporting documents as described above. These documents include: - A copy of the diagnosis from the applicant's physician -OR- a copy of the applicant's IEP -A vendor-written cost quote including shipping and handling fees -Written recommendation from therapist or physician (for therapies or equipment requests) -A copy of the previous year's Federal Tax Return (top page only) with all W2s -A copy of SSI/SSDI award letter for parents (if applicant is a minor) or individual (if over 18) -Proof of child support payments, alimony, pensions, ADC, etc. (if applicable) -Proof of income for self-employment or unemployment compensation (if applicable)

Email supporting documents to: deepwood.foundation@lakebdd.org