State Aid Funds Application

State Aid Funds Application
State Aid requests must be received in the same fiscal year in which the service was provided (July 1 - June 30).

Please see CDDO Procedure for State Aid before completing the form.
Name of Person Served:*

First NameLast Name
Date of Request:*

MonthDayYear
Amount Requested:*
Affiliate:*
Explain the current situation that warrants the request for State Aid:
What community resources have been previously exhausted?
Upload any supporting documents (including case notes, etc.):

Cancelof
Explain how funds may increase adaptive capabilities, productivity, independence, and/or inclusion:
For TCM requests only:

Please check this box if Affiliate is only requesting payment for case management services during a crisis, for an individual not yet eligible for Medicaid.
Documentation of other available community resources previously exhausted:
Submit the plan which outlines the barriers and needs of the person to provide day or residential services, the equipment, modifications, or supports that will address the need(s) of the person:
Bids upload:

*Bid requirements: One bid for anything under $10,000. Three bids for anything over $10,000.
Cancelof
Plan for addressing barriers:
For Affiliates requesting funds for case management services, emergencies, property damage, or community disasters; please explain the current situation:
Signature*

Clear
Name of Person Completing Form:
Title:
Email Address:
example@example.com
Date

MonthDayYear
Should be Empty: