Permanent Accessibility for Temporary Housing (PATH) Flash Grant

Tornado Relief Application

Eligibility

Any person with a disability who is a resident of Kentucky and who is or is willing to become a consumer with our agency can be eligible for assistance. As a consumer of the agency, an individual must have an active independent living goal and be working with our staff to achieve that goal. The definition of disability is a physical or mental impairment that substantially limits a major life activity such as caring for oneself, walking, seeing, hearing or speaking.

In addition to the disability requirement, applicants must earn less than 200% of the poverty level as determined by the U.S Department of Health and Human Services (HHS).

Direct Financial Support that can be requested

Applications will be assessed based on need and documentation of that need. Things that can be requested include financial assistance small home modifications, durable medical equipment, grab bars etc. Other expenses based on individual needs may be allowed.

All requests must be directly related to circumstances caused by the December 10 tornado. Please be aware that financial assistance payments will go directly to the entity in which the payments are made. No cash will be directly delivered to the consumers.

Application Review

Applications will be reviewed by staff and will be funded based off the criteria caused by the December 10 tornado. The evaluation will be based on need, the documentation of that need, and whether the applicant has demonstrated that the assistance requested will facilitate or support the individual maintaining their independence in the community. In addition, applications will be reviewed to ensure there are no other means for addressing this issue. Referrals will be made to other organizations if the need can be met somewhere else. This is intended as payment of last resort to assist our consumers who have no other means of support disaster after aftermath. Staff may ask for verification or documentation of the requested items. Financial eligibility will be assessed.

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* 1. Contact Information

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. County

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* 3. Race (Optional)

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* 4. Date of Birth

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* 5. I attest that the information submitted in this application is true and I understand CAL Staff confirm this information in order to make a determination about funding this application

Name

Date

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* 6. What is your disability? Briefly explain how it affects your life.

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* 7. Please enter the amount of assistance you currently receive.

Social Security Disability (SSDI)

Supplemental Security Income (SSI)

Unemployment

Workers Compensation

Section 8 Assistance

Medicaid/Medicare

Medicaid Waiver Assistance

Food Stamps (SNAP)

Other

Total

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* 8. If you entered any amount in 'Other' above, please specify the source of those funds.

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* 9. How have you been impacted by this disaster? Please explain in length.

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* 10. What are you requesting assistance for?

Small Home Modifications

Portable Ramp

Durable Medical Equipment (please list below)

Grab bars

Other (please specify)

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* 11. For each item checked above, please specify the amount in dollars of assistance being requested. Also include the total amount being requested.

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* 12. Explain how the financial assistance or supports will make a difference in your life: Click or tap here to enter text.

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* 13. If you receive financial support, what goals can we assist you with in maintaining your independence in the community during this time?

Please provide supporting documentation to your request by emailing to cjohnson@calky.org or faxing it to (270) 753-7729. This could include, but is not limited to:

Ø If renting -Letters from landlord letters of approval are attached. (For grab bars home modifications are ramp installation

Ø Include estimates for any items requested.

Ø Please provide verification of income with- copies of your SSDI or SSI award letters or verification of unemployment insurance and food stamp benefits.