THE GONZALES TRUST COMMUNITY LIVING REQUEST FORM

Requests will be presented quarterly to the Gonzales Trust Committee for review. Approved requests will be forwarded to The Arc of the United States for final approval. Requestees will be notified of the Committee’s decision. If more information is necessary for review, you will be contacted by Alexandria Lofton, Trust Director, The Arc of New Mexico.

The following criteria apply to this request:

· Applicant must be a person with Down syndrome who legally resides in New Mexico or a family member or legal guardian applying for services/supports.

· Grants are limited to $7,500 annually per household—payments are not made directly to the individual or family. The Arc of New Mexico will pay the vendor, service provider, educational institution, organizing agency, or merchant directly for the approved service or support.

· Eligible purchases: 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, fees for individualized job coaching/training or other special tutoring.

· Eligible expenses would be for services that are not available to the individual through other reimbursed or directly funded insurance, Medicaid State Plan, DD waiver, Voc. Rehabilitation.

· Applicants can receive a lifetime maximum of $15,000.

Question Title

* REQUESTER'S INFORMATION

Requester's Name:

Date:

Requester's Address:

Phone #:

E-mail:

Signature of Requester, Guardian, POA:

Print Name:

Question Title

* Business, organizing agency, or service provider to be paid:
Please do NOT list yourself or another individual person

Company:

Address:

City:

State:

Zip Code:

Phone #:

Question Title

* TOTAL AMOUNT REQUESTED INCLUDING TAX AND DELIVERY $

Question Title

* Have you received $7,5000 in funds in the last year in the community living category?

Yes

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* How much, if any, have you received in total funds in the community living category?

The application will be assessed on the following criteria:

Question Title

* What are funds being requested for?

Question Title

* Please describe structure and attendance of your program's classes, workshops, activities, etc...

Question Title

* What are the personal or professional goals you would like to realize?

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* How does this program help you realize your professional goal?

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* How does this program advance inclusion of individuals with Down syndrome in the community?

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* Is this a need that is not fulfilled by other programs? Please explain why funding is required.

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* Is there anything else important about the request that you would like to share?

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* Invoice or budget breakdown: Until you send a quote, invoice, or budget breakdown, your application will be incomplete for consideration.

I acknowledge that I must email an invoice or budget breakdown to myoussef-arafat@arcnm.org for my application to be complete.

THE GONZALES TRUST COMMUNITY LIVING REQUEST FORM

Question Title

* REQUESTER'S INFORMATION

Question Title

* Business, organizing agency, or service provider to be paid:**Please do NOT list yourself or another individual person**

Question Title

* TOTAL AMOUNT REQUESTED INCLUDING TAX AND DELIVERY $

Question Title

* Have you received $7,5000 in funds in the last year in the community living category?

Question Title

* How much, if any, have you received in total funds in the community living category?

Question Title

* What are funds being requested for?

Question Title

* Please describe structure and attendance of your program's classes, workshops, activities, etc...

Question Title

* What are the personal or professional goals you would like to realize?

Question Title

* How does this program help you realize your professional goal?

Question Title

* How does this program advance inclusion of individuals with Down syndrome in the community?

Question Title

* Is this a need that is not fulfilled by other programs? Please explain why funding is required.

Question Title

* Is there anything else important about the request that you would like to share?

Question Title

* Invoice or budget breakdown: Until you send a quote, invoice, or budget breakdown, your application will be incomplete for consideration.

* Business, organizing agency, or service provider to be paid:
Please do NOT list yourself or another individual person