IOMOTC Special Needs Assistance Fund (SNAF) Application

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Application to assist families with multiple birth children meet the extraordinary expenses associated with raising a special needs, chronically ill or catastrophically injured child or immediate family member.

Email *

Parent Name *

Address *

City *

State *

Zip Code *

Telephone Number *

Email Address *

Name of Multiples Club

Monetary Amount requested *

Money will be used for: *

Equipment

Therapy

Medicine

Medical Services

Other:

Required

Name of Person needing assistance *

Please provide details of how the money will be used: *

Reason why money is requested: *

Not Covered by Insurance

Can't afford deductible

Income not sufficient

Other:

Required

Medical Diagnosis for Recipient *

Financial Services Currently Being Utilized *

Private Insurance

Medicaid

WIC

Other:

Required

Employment Information *

Both Parents Employed

One Parent Employed/One Stay At Home Parent

Unemployed

Other:

Required

Please add any other information that you feel would help the committee understand your request for funds.

Submit

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