Application For Assistance

Personal Information

This information is required by the foundation based on its charter with the IRS. All Information will be held in strictest confidence and will not be shared with any public or private entity. The foundation reserves the right to ask for documentation of any of the below listed financial information.

*The Joseph S Groh Foundation does not provide cash as a means of assistance. Assistance is provided in the form of payment for materials or services needed by the applicant, and payment is made directly to the supplier. The foundation reserves the right to seek additional information before making a decision about a request. This information will typically be sought either by email or phone.

*Name of Applicant:

Applicant's Address

*Address:

*City:

*State/Province:

*Postal Code:

*Phone Number:

*Email address:

*Describe Your Career in the Construction Trades Industry:

*Describe in Some Detail Nature of Disability:

*Please Describe How and When Disability Occurred:

*Describe Where You Learned about Our Foundation:

*Type Of Assistance Desired: Please help us understand the type of assistance you are looking for in terms of equipment (i.e. home & bath remodel, Hoyer lift, wheelchair van, assistive technology, rehabilitative equipment etc.):

*Please List the Dollar Amount of Requested Assistance:

*Name of Potential Providers:

*Phone Number of Potential Providers:

*Financial Information* Please describe what impact this disability has had on your financial situation:

*Please describe what insurance coverage you have relative to this disability:

*Please describe any other benefits you are receiving for this disability, including SSDI or a private disability policy:

*Are you working with any other charities regarding possible assistance, and if so, what types of assistance might they provide?:

*Please describe how you anticipate the funding of this request will change or improve your situation? What will it allow you to do that you cannot do now?:

*Our foundation is very small, and unfortunately we have more grant requests than we can fund. Please tell us what is unique about your situation, needs or circumstance that would cause our board to fund it over some other compelling requests?:

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