1 2019 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.

Last revised August 22, 2016

OMB Control No. 3045-0179

Expiration Date: 08/31/2019