Funding Application (For Kansas Residents Only)

5111 East 21st Street
Wichita, KS 67208


UCP of Kansas
Application for Financial Assistance

Client’s Name_____________________________Age________Birthdate__________

Address________________________________________________________________

City______________County_____________State____Zip________Phone(___)__________

Parent’s Name(s) (if client is a minor)____________________________________________

Father’s Place of Employment__________________________________________________

Mother’s Place of Employment_________________________________________________

Client’s Place of Employment__________________________________________________

Disability or Diagnosis________________________________________________________

Date of onset of disability (at birth)_____________________(other)____________________

Equipment requested__________________________________________________________

Total Cost $______________Amount family can contribute toward cost _____________

Amount requested from UCP $________________

Have other agencies or groups been contacted for assistance?
Yes_____ No_____
If Yes, which agencies and what were the results?

Will your personal insurance cover any or all of the equipment requested?
Yes_____ No_____
If Yes, how much?__________________________________________

Name of Insurance Company_____________________________________________

Is client eligible for and/or receiving assistance from: (circle one) Health Wave Yes No Social Security Yes No Supplemental Security Income (SSI or SSDI Yes No Kansas Special Health Services Yes No Medicaid Yes No Medicare Yes No

Do you have a prescription or professional recommendation for the item requested?
Yes_____ No_____
If Yes, from whom? _______________________________

Gross annual family income $_________
# of persons living in the household _____

I verify that the information provided above is accurate and agree to complete a follow-up questionnaire if provided with financial assistance.

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Signed__________________________________________

Dated___________________________________________

Please return completed form to:

UCP of Kansas P.O. Box 8217 Wichita, KS 67208


URL: http://www.ucpkansas.org


Updated: 05/16/2006