Application for Financial Assistance

 

At the Spina Bifida Coalition of Cincinnati, we understand that the unexpected costs of living with spina bifida can sometimes exceed your budget. To assist in meeting these emergency expenses, we offer up to $300 each year to help with medical, housing, utilities, and other critical expenses. Please let us know in the comments section below if payment is necessary to avoid eviction or service disruption. Although we try to accommodate everyone, financial assistance is limited and offered on a first come, first served basis, annually. 

 

Person with Spina Bifida Who Needs Assistance

Name of Participant
Date of Birth
County

Form Completed By:

Country
State / Province*
Address
City
Email*
Confirm Email*
Phone

Type of Assistance Requested

What Type of Assistance is Requested?
  • Emergency Medical Expense
  • Rent or Mortgage Payment
  • Utilities Payment
  • Other
To Whom Should We Write the Check
Amount Requested

This form must be submitted with supporting documentation (invoice or bill) prior to payment. Payments will only be paid to the provider, not the individual. Invoices can be emailed to sbccincy@sbccincy.org or faxed to 513-914-4931. An acknowledgement will be sent to you when a payment has been made. 

 

By submitting this application, I certify that all the information provided is true and correct. I certify that the items listed are for the benefit of the applicant. If any information is intentionally false, I agree to reimburse SBCC all costs, legal and otherwise, to recover the disbursed funds.

Additional Comments

Security Code

Share This Form

Powered by eTapestry.