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THE GONZALES TRUST COMMUNITY LIVING 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.

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 $7,500 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 those not available to the individual through other reimbursed or directly funded sources, such as insurance, the Medicaid state plan, DD waiver, etc. Examples: tuition for classes or courses that help a DS applicant meet personal or professional goals, cost of attendance at music, athletic, art or other camps or workshops, fees for gym memberships, fitness training, social clubs, organized recreation programs, or fees for individualized job coaching/training or other special tutoring.
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 community living category? Example: in 2021, we received $3,000 for our child to go to the Down Syndrome National Conference. (Required.)
4.Total amount of request, including tax and delivery. Request cannot exceed $7,500.(Required.)
5.List each expense item and the projected cost of the item(s). Example: $2,500 for the National Conference, to include $1,000 for airfare, $1,000 for hotel, and $500 for food. (Required.)
6.What is the purpose of the requested funding? Select all that apply.(Required.)
7.Provide a detailed description of the purpose and intended use of the requested funds, and how it will directly benefit the person with Down Syndrome. Include structure, frequency, duration, and other details. Example: our daughter would go to the DS National Conference in July, and would learn about transitional living, employment, self advocacy, and socialization, to increase her quality of life.
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).
9.Is this a need that is not fulfilled by other funding programs? (Medicaid State Plan, DD Waiver, Vocational rehabilitation, etc.) Please explain. Example: we would purchase the plane ticket, hotel, and food and submit receipts for reimbursement. (Required.)
10.When is the funding needed? If time-sensitive, please specify the deadline. Example: the conference is in July, and we would need to know by May
11.What are the personal or professional goals you would like to realize for the individual, and how will this funding aid in those goals?(Required.)
12.How does this program advance inclusion of individuals with Down syndrome in the community?(Required.)
13.Is there anything else important about the request that you would like to share?