Form 1 Disability Accommodation Request Form

Disability Accommodation Reimbursement Grant Request Form

Please provide all the requested information to ensure timely processing of your request. Requests are not complete unless a receipt is attached.

1. Were outside community resources consulted in securing partial funding for or arranging
   accommodation, such as coordinating with the Department of Vocational Rehabilitation?
   No ____ If Yes, please describe:

2. Name of Applying Organization:

3. Grant Number:

4. Organization Single Point of Contact Name for Request:

5. Single Point of Contact Email Address:

6. Single Point of Contact Telephone Number:

7. Attention to and address to which the check should be remitted:
   
   Note: The prime applicant must indicate knowledge and approval of the accommodation reimbursement request. All payments will be made to the prime grantee only.
   
   
   

8. Member NSPID(s):

9. Type of Disability:

10. Type of Accommodation:

11. Please provide a brief statement as to how the accommodation helps the member(s) achieve full participation in their service assignment(s):

12. Requested Reimbursement Amount: $

13. Is this a one-time reimbursement request or a quarterly request for multiple reimbursements?
    One-time _____ Quarterly _____

Please batch multiple requests into quarterly submissions with an itemized summary.

14. If this is not a one-time request and you foresee batching receipts on a quarterly basis, what is your projected cost for the fiscal year for this member (please provide cost, not a range): $

The completed request form must be submitted via email to [email protected] with organization name and the NSPID in the subject line of the email.

Reimbursement payments will be made on a first-come, first-served basis until funds are exhausted once a completed request form is submitted with attached receipts

OMB Control Number: Expiration Date:

Burden Statement: Public reporting burden for this collection of information is estimated to average 10 hours per submission.

Privacy Act Statement: The Privacy Act of 1974 (5 U.S.C. § 552a) requires that the following notice be provided to you: The information requested in the Disability Assistance Request Form is collected pursuant to 42 U.S.C. 12592 and 12615 of the National and Community Service Act of 1990 as amended, and 42 U.S.C. 4953 of the Domestic Volunteer Service Act of 1973 as amended, and 42 U.S.C. 12639. Purposes and Uses - The information requested is collected for the purposes of reviewing applications and granting funding requests. Routine Uses - Responses to this information collection will be disclosed as appropriate unless prohibited by law. Effects of Nondisclosure - The information requested is mandatory in order to receive benefits.