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THE GONZALES TRUST INDIVIDUAL REQUEST FORM

Requests will be presented quarterly to the Gonzales Trust Committee for review, then forwarded to The Arc US for final approval. Requestees will be notified within 10 days of Arc UW review. You may be contacted If more information is necessary for consideration.

Beneficiary. This funding must directly benefit a person with Down Syndrome who legally resides in New Mexico. Alternately, this funding may be used for a family member or guardian of a person with Down syndrome to attend a conference and/or receive education or training that directly benefits the person with Down syndrome.

Applicant. The applicant must be the individual with Down Syndrome, or their family member or legal guardian applying for services/supports on their behalf.

Award Amount. Grants are limited to $5,000 annually per household, with a $15,000 lifetime cap.

Payment Method. Payment will be made directly to the vendor, contractor, agency, or merchant for the approved service or program. Under special circumstances, individuals may be reimbursed with prior approval, upon production of receipts.

Eligible purchases. Allowable expenses include items, devices, or services that are not available to the individual through other reimbursed or directly funded sources, such as insurance, the Medicaid state plan, DD waiver, etc. Examples may include cellular phones, tablets, computers, specialized home modifications, communication devices, transportation services not covered by other programs, vehicle modifications, or adaptive equipment not available through standard service programs.

1.REQUESTER'S INFORMATION(Required.)
2.What is your relationship to the individual with Down syndrome?(Required.)
3.Have you received funding previously from the Gonzales Trust in the individual support category? Example: In 2021, we received $3,000 for our daughter to buy an adaptive bed.(Required.)
4.Total amount of request, including tax and delivery. Request cannot exceed $5,000.(Required.)
5.List each expense item and the projected cost of the item(s). Example: $3,000 to purchase a full size, adaptive bed and mattress. (Required.)
6.What is the purpose of the requested funding? Select all that apply.
7.Provide a detail description of the purpose and intended use of the requested funds, and how it will directly benefit the person with Down Syndrome. Example: an adaptive bed would help our daughter get in and out of bed safely.(Required.)
8.Please explain how you plan to acquire the requested product or service. Note that funding is issued only as reimbursement (upon submission of receipts) or direct payment to a vendor. If selecting vendor payment, include the vendor’s name and contact information (address, email, phone, and website, if applicable). Example: we will purchase the bed from Sears, and provide an invoice for payment.
9.Is this a need that is not fulfilled by other funding programs? (Medicaid State Plan, DD Waiver, Vocational rehabilitation, etc.) Please explain. Example: Yes; while we get the DD Waiver, we do not qualify for an adaptive bed. (Required.)
10.When is the funding needed? If time-sensitive, please specify the deadline. Example: we are moving in October and need the bed before then.
11.Is there anything important about the request that you would like to share?