The Joseph Groh Foundation - Receiving Assistance

	Receiving Assistance

	Information

Application For Assistance

Personal Information

This information is required by the foundation based on its charter with the IRS. All Information will be held in strictest confidence and will not be shared with any public or private entity. The foundation reserves the right to ask for documentation of any of the below listed financial information.

Name of Applicant:

Applicants Address Including City, State, & Zip Code

Phone Number:

E-mail Address:

Describe Relationship to Construction Trades Industry::

Describe in Some Detail Nature of Disability:

Please Describe How and When Disability Occurred:

8. Describe where you learned about our foundation.

Type Of Assistance Desired:

Please help us understand the type of assistance you are looking for in terms of equipment (i.e. wheelchair, patient lift, wheelchair vans, assistive technology etc.) and/or the types of services you are seeking assistance/reimbursement for. (i.e. ramps installed into the house, door widening, bathroom remodel for wheel in showers etc.) In addition, please list the estimated dollar amount of requested assistance.

Financial Information *

Please describe what impact this disability has had on your financial situation:

Please describe what insurance coverage you have relative to this disability:

Please describe any other benefits you are receiving for this disability

* It is the policy of the Joseph S. Groh Foundation not to provide cash as a means of assistance. Assistance is provided by payment for materials/ services needed by or rendered for the applicant. The foundation reserves the right to seek additional information before making a decision about any request. This information will typically be sought either by phone interview or via a more detailed application. Before a grant is made, the foundation must be provided names and phone numbers of the product and/or service suppliers, as per foundation policy.



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