Family Support Advisory Council

FAMILY SUPPORT ADVISORY COUNCIL REQUEST FOR FINANCIAL ASSISTANCE

Date of Request: ______

I am requesting financial assistance from the FSAC for the following need of my family member: (Please provide as much detail as possible. Write on back if you need more space) ______

Other resources that are helping me with this cost?______

My family is contributing $______The amount I request from the FSAC is $______Has the FSAC granted you assistance since July 1st of this fiscal year? ______If so, how much? ______

______Mailing Address:______Eligible Family Member’s Name (Please print) ______Parent/Guardian’s Name (Please Print)

______Parent/Guardian’s Signature

Please return this request form to your service coordinator in the Family Support Department. Your name will be deleted from the request to ensure confidentiality.

DECISION: to be completed by Family Support Advisory Council:

Approved or denied? ______Amount to be granted: ______Date of Decision: ______

Signature of Chair/Designee: ______Paid Ck. # Date

If denied, explanation:______

Acct. Amt. ______

FS Director’s Signature:______