Nebraska Ataxia - Grant Application
Please complete the first page in its entirety. Then complete the categories relevant to your request. If the information requested is unknown or doesn't apply, please write "unknown" or "NA".
Email address *
Nebraska Ataxia Grant Guidelines and Limitations
Please read this entire section as it contains important information about the grant process.

The grant process can take up to three months from receipt to approval. If you have a time sensitive application please contact Nebraska Ataxia by email after filling out the grant application and mailing all pertinent information.

Nebraska Ataxia does not provide funds directly to individuals. Nebraska Ataxia does not reimburse individuals for expenses already incurred. All application requests must be filled out, submitted, and approved prior to any purchase or payment being made. Nebraska Ataxia reserves the right to fund a grant in any amount regardless of the amount requested. If approved, Nebraska Ataxia will pay the service provider directly. For durable medical appliances and exercise equipment such as walkers, wheelchairs, canes, recumbent bicycles, etc. we ask that when you no longer need an item that you donate that item back to Nebraska Ataxia.

In addition to the information in the grant application below, we request that the applicant either mail or email the following information:

1. short essay from the applicant explaining their condition and why the grant is being requested
2. letter of diagnosis (if diagnosed by a physician)
3. letter of referral from a medical professional (physical therapist, physician, nurse, etc)
4. statement of approval or denial of any other financial services requests
5. recommendation or prescription from medical professional (physical therapist, physician, nurse, etc)
6. statement showing monthly income (W-2, SSI Year End Statement, SSDI Year End Statement, Tax Return)
7. statement showing monthly expenses (rent, mortgage, utilities, loans, etc)

Please be sure to hide/redact any sensitive information such as social security numbers, bank account numbers, routing numbers, etc. Nebraska Ataxia is not responsible for loss or leaking of any sensitive information that is not hidden/redacted.

Applications will not be considered until the above information is received by Nebraska Ataxia. Statements can be sent to one the following addresses.

Mail:
Nebraska Ataxia
Attn: Grant Requests
P.O. Box 24214
Omaha, NE 68124

Email:
grants@nebraskaataxia.org
Subject: Grant Request Additional Information

By accepting a grant provided to you by Nebraska Ataxia you agree to allow Nebraska Ataxia to use the applicants name, story, and likeness to help promote Nebraska Ataxia and it's services.

By checking the acknowledgment below you state that all of the information herein is accurate and true, and that Nebraska Ataxia may use any of the information provided in making an informed decision on whether or not to approve the request.

Nebraska Ataxia, Inc. is an IRS approved 501(c)(3) nonprofit organization Tax ID #81-2926708.

Acknowledgment *
Required
Name of Person completing the application? *
Your answer
Relation to person with ataxia? *
All questions from here on will be about the person with ataxia that the application is being filled out for.
First Name *
Your answer
Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone Number *
Your answer
Has the applicant been diagnosed with ataxia? *
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