OHIO DD COUNCIL EMPOWERMENT FUND APPLICATION FORM FOR SERVING ON A COMMITTEE OR BOARD

Please photocopy this blank form before completing, for use as a worksheet.

Name: ____________________________________ Date: __________

Address: ______________________________________

City: ____________________________________ State: ______ Zip: _____

Phone: ________________________________________

Check one:

• I am a person with a disability
• I am an immediate family member of a person with a disability
• I am the guardian of a person with a disability

Name of Committee, Board, Commission or group on which you will serve:

Chairman/Director:

Address: ______________________________________

City: ____________________________________ State: ______ Zip: _____

Phone: ________________________________________

E-mail: _______________________________________

Brief explanation of purpose of the committee:

Brief explanation of your reasons for serving on the group:

How often does it meet?

Amount you and/or third parties can contribute to attend this program:

I can contribute: $
Other organizations can contribute: $
Name(s) of other organizations:

If you can’t contribute anything yourself, or get some of the cost covered by another organization, please explain your efforts to obtain alternative funding.

Amount of financial assistance you are requesting from the Council:

• Transportation $
• Lodging $
• Personal Assistance Services* $
  (maximum $10/hour)
• Other $

Please tell us what will work better for you:

_____ I will pay my expenses and wait for a reimbursement check after I send in my receipts.

_____ I will need the money before I go and will send in the Receipts afterward.

Certification Statement to be Signed by Applicant:
If I am approved for funding, I will agree to turn in receipts for all the money I used, along with a meeting agenda. I understand that the receipts and agenda must be turned in to the DD Council within 15 days. I certify that I will return all other funds (the money I don’t have receipts for).

Signature ______________________________

Certification Statement Regarding Personal Assistance Services:
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 event and that another funding source cannot pay for these hours.

Complete this form and send it, whenever possible, 40 days before the first meeting you plan to attend.

Ohio Developmental Disabilities Council
Attn: Carla R. Sykes
8 E. Long Street, 12th Floor
Columbus, Ohio 43215-2931

| Home | About Us | Calendar of Events | Grants and NOFAs | Links | Publications and Products | Site Map | What's New |