Good Neighbor Grant Application

Date

Name *

First

Last

Date of Birth

Town of Permanent Residence:

Home Phone

Cell Phone

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

is of should

Do you own a home computer?

Do you have access to the internet at home?

Do you currently have health insurance?

If yes, what is the name of the insurance company?:

Total number of members in the household:

Ages of all household members:

Average household total monthly earned income (wages, bonuses, etc.):

If urgent, please indicate here

What other resources have you contacted or utilized to help you reach your health care needs?

Is there anything else you think we should know when considering your application?

RELEASE OF CONFIDENTIAL INFORMATION: I hereby authorize the agencies or persons listed below to release to the Ottauquechee Health Foundation for its use of any information in my records maintained by any of the designated agencies or persons that is relevant or necessary for the purpose of providing assistance for my needs.

Name of person or agency, Type of provider, Phone Number

Name of person or agency, Type of provider, Phone Number (copy)

Name of person or agency, Type of provider, Phone Number (copy) (copy)

I give the Ottauquechee Health Foundation permission to send health information back to the above listed persons, providers or organizations.

Name and Date (Electronic Signature)

Please attach a copy of your most recent tax return or comparable document (showing total household size and total household income) to this application and submit

Click or drag a file to this area to upload.

Good Neighbor Grant Application Instructions

Good Neighbor Grants are designed to make funds available to individuals residing in the Foundation Service Area who require assistance with their personal health care needs.

Foundation Service Area
The Foundation service area includes nine towns—Barnard, Bridgewater, Hartland, Killington, Plymouth, Pomfret, Quechee, Reading, and Woodstock, Vermont.

Use of Funds
The Foundation makes grants as needed for individual needs, such as eyeglasses, hearing aids, medical supplies, prescriptions, and medical and dental bills. Funds will be distributed to the agency or provider of the service, not to the individual applicant. Funds have to be granted before treatment starts and will be paid after treatment is complete. Approved grants will have an expiration date. Treatment must be completed by expiration date indicated on the Good Neighbor Grant Letter of Agreement.

Eligibility
• Good Neighbor Grants will be accepted for consideration only after all resources have been exhausted. This includes but is not limited to Medicare, Medicaid or other state programs. Hospitals may also offer programs which forgive or reduce monthly costs.

• Good Neighbor Grants are made based on financial need—both income and ability to pay. Please provide a copy of your past year’s tax return. If you have special financial circumstances, please describe them briefly.

• Applicants must reside in the Foundation’s service area and provide a proof of residence.

Application Process
The applicant seeking funds will complete and submit the attached application to the Foundation. Requests of $500.00 or less can be approved by the Executive Director. Requests over $500.00 need to be approved by The Grants Committee. This committee, made up of several OHF Board Members meets monthly. For requests of $5,000 or more, the Board will act on the request at its next Board meeting. The applicant will be notified of the final decision on his/her application within seven (7) days of a decision.

Application Checklist
• Completed and signed Good Neighbor Grant Application (attached)

• Signed copy of most recent income tax return (if you do not file a tax return, please contact our office so we can offer you other option