Date: __________ OHIO DD COUNCIL EMPOWERMENT FUND APPLICATION FORM FOR CONFERENCES Please type or print clearly. Name: ____________________________________ Address: ______________________________________ City: ____________________________________ Zip: _____ Phone: ________________________________________ E-Mail: _______________________________________ Check one:
Title of conference you are requesting funds to attend: _____________________________________________________ _____________________________________________________ Conference Location: ______________________________ Conference Date: __________________________________ Conference sponsor: ________________________________
Have you attended this conference before? Why do you want to attend this conference?___________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Have you applied to the Empowerment Fund before? Was request What event was request for:______________________________ How much can you or other people, organizations, or companies contribute for you to participate in this group? I can contribute: $__________ If you cannot contribute anything, explain what you have done to try to get some of the costs covered: If others are contributing to your expenses, list them: How much financial assistance are you requesting? TOTAL $________________ Give names of all people that will be attending with you: Spouse ____________________________ Child with a disability _____________________________ Other child and age ________________________________ Other child and age ________________________________ Other child and age ________________________________ Other person _______________________________________ Empowerment Fund awards will be made as reimbursements for expenses incurred. Advanced funding may be made available upon request only to individuals who receive SSI, SSDI, or TANF. (Please see "Advance Funding Request" at end of application)." CERTIFICATION STATEMENTS 1. Applicants requesting personal assistance services must sign this statement. I normally use personal assistance services _____ hours per day. I certify that I am requesting assistance for only the actual hours a personal assistant will be working for me during this conference. These hours will not be paid for by another source. Signature ______________________________ 2. All applicants must sign this statement. If I am approved for funding, I agree to submit original receipts, a conference agenda, a summary report, and a completed volunteer services report to the DD Council following the event. I understand these items must be received by DD Council within 45 days after the end of the conference. I certify that if I receive advanced funding, I will return any portion of the award that goes unused or for which I do not submit receipts. Signature ______________________________ Advanced Funding Request To be completed only be applicants requesting to receive their award prior to attending a conference and currrently receive SSI, SSDI, or TANF. By signing, I am declaring that I receive Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), or Temporary Assistance for Needy families (TANF). I understand that I may be approved to receive funds prior to attending this conference and that I am responsible for submitting original receipts and returning any unused funds to the Empowerment Fund. Signature ______________________________ Date ______________________________ Completed applications, and conference agenda, must be received at least 40 days prior to an event at the following:. Ohio Developmental Disabilities Council If you have questions, contact: FOR COUNCIL USE ONLY Date received in office ______________ Initials _________ | Home | About Us | Calendar of Events | Grants and NOFAs | Links | Publications and Products | Site Map | What's New | |