Grant Application – Mobility Assistance 2019 Q4

all fields required (if info requested is not applicable or available, type NA)

Full Name

Street Address

City

State/Province

Zip/Postal Code

Home Phone

Work Phone

Cell Phone

Email

List all persons who reside at the above address (Full Name, Relationship, Age - one per line please)

Employment History of applicant or head of household (past five years – Company, Job, Years, Reason for Leaving - one per line please)

Are other members of your household employed? If so, please list name and current company/position

What is the total combined annual household income? (Please include child support, alimony, unemployment compensation benefits, sick benefit, interest income, social security benefits or any other unearned income.)


Please attach verification of the above answer. Summary pages of your most recent federal income tax return are preferred (do not send all pages of your tax return). Cover or cross out your social security number! If you cannot provide a tax return, paycheck stubs (minimum of two months required), benefit award letter, etc. may be submitted

IMPORTANT! The size of each file must be smaller than 5 Megabytes!





For what other assistance have you applied? Include grants, loans, funding opportunities, etc. along with determination and any amounts awarded.

What other assistance have you received? If assistance was not received, what was the reason for denial?

If you are a college student, are currently working or planning to work, have you applied for Vocational Rehabilitation Services through your state?

Were you approved for services?

If not, please list reason for denial


If you are a Veteran or currently serving in the military, have you applied for the VA Automobile Adaptive Equipment Program or Automobile Allowance?

Were you approved for either of these programs?

If not, please list reason for denial


Have you performed any fundraising activities or have any been performed on your behalf? What were the results?

If selected to receive a grant from NOVA, the maximum amount awarded will be 25% of the cost of the mobility product(s) with a cap of $5,000. Describe in detail the funds you have secured and how you will pay the remaining balance (please include loan pre-approvals, other grants awarded, fundraising dollars received, etc.).

Narrative of your situation. Please share your story and include information concerning your condition or situation requiring a vehicle modification, type of mobility device used (i.e. manual or power wheelchair, scooter, walker, etc.), quest for assistance, and the equipment suggested to meet your needs.

Conditions of the Grant

STOP HERE! Visit http://www.nmeda.com/locate-dealer/ and enter the zip code of your mobility dealer where indicated on the dealer locator page. If your mobility dealer's name does not appear on this page, your application cannot be considered. All additional funding for the mobility transportation equipment must be secured. If the grant application is funded the check will be written to the dealer to complete the transaction. Grant amount may not exceed 25% of total mobility product(s) purchase.

Dealer Name

Name of Mobility Consultant/Sales Representative

Address

City

State/Province

Zip/Postal Code

Phone

Please upload a copy of the quote/estimate from your dealer. Please confirm that your dealer is certified by the National Mobility Equipment Dealers Association (NMEDA) at the following link: http://www.nmeda.com/locate-dealer/. If your dealer is not listed on this website, we will be unable to process your request. All quotes must be on official letterhead provided by the dealer and list your name as the customer, indicating that this is a personalized quote.

IMPORTANT! The size of this file must be smaller than 5 Megabytes!

Before submitting your application, please confirm that you have completed each of the required items by checking each box below:

I have attached a quote from a NMEDA certified dealerI have attached proof of income for all household membersI have provided a detailed description of need for assistance. Your story is very important! Please include details such as type of assistive device used (i.e. power or manual wheelchair, scooter, walker, etc.), physical limitations, age of individual(s) in need, current method of transportation, special needs of caregivers, any special circumstances, etc.I have provided information indicating that other funding sources have been sought (including whether your request was approved or denied)I have documented that the majority of the funds have been secured to complete this project. This includes pre-approval for a loan if needed.

If any of this information has not or cannot be provided at this time, please do not submit your application as it will not be considered for funding.

By entering your name and clicking on the "Submit My Application" button below, you acknowledge that you understand and agree to 1) the Application Rules, 2) the Conditions of the Grant stated above, 3) grant permission for representatives of The National Organization for Vehicle Accessibility to share and exchange information with the mobility dealer listed on the application or quote for the purpose of providing assistance. This may include sharing information about the applicant’s disability, and 4) grant permission to use the name, story, photographs and/or video of the grant recipient for print and/or electronic use by The National Organization for Vehicle Accessibility for purposes such as publicity, illustration, advertising, and Web content. I understand that by typing my name and clicking "Submit My Application", I am electronically signing this document.

Applicant's Signature*