Family Support: Discretionary Funds Application: Gateways Community Services : Nashua, NH

Family Support

Discretionary Fund Application

Enrolled Member's Name:

Name of Person Requesting Funds:

Address:

City, State, ZIP

Best Phone Number to Use:

Best E-mail Address to Use:

Date of Request:

Amount Requested:

In answering the following questions, please include the following information: number of individuals involved, nature of activity, date, time and place of activity, is this something that Gateways Community Services could share with other families receiving services, and any other information that would be helpful in understanding your request.

What is your request:

How will this benefit the individual/family?

Check this box if this is a reimbursement

Other Funding
Please list any other sources of funding you are currently utilizing, have accessed in the past, or have applied for: (Harry Alan Greg, Mini TASH, School, etc.)

Contact Person and Address where funds should be sent upon approval:

Contact Person:

Address:

City, State, ZIP

For our mutual protection, to submit your inquiry please key in the security code shown below:

(Can't read this one? Click to generate another.)

Enter the Security Code here:

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