Application for Services/Funding from SMA Support

Name & Address of Adult Applicant:
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_____________________________________________________________________________________________
_____________________________________________________________________________________________

Phone # of Applicant:
______________________________________________

E-mail Address of Applicant:
______________________________________________

If different, name of SMA Individual:
______________________________________________

Age and Estimated Type of SMA Individual:
______________________________________________

What is your specific request of SMA Support:
______________________________________________________________________________________________
______________________________________________________________________________________________

Why is this request important to quality of life, and/or what additional comments would you like to make:
______________________________________________________________________________________________
______________________________________________________________________________________________

For direct equipment purchases, SMA Support will need a quote directly from the provider of the equipment which includes their name, address, phone, and specific information on the equipment as well as its quoted price.  Please attach with application.

For direct services purchases, SMA Support will need a quote directly from the provider of the services which includes their name, address, phone, and specific information on the services to be provided as well as their quoted price.  Please attach with application.

I have read and understand the RULES/POLICIES prior to sending this application:
______________________________________________
Signature of Applicant


Please submit this application via email, fax, or mail to Laura Stants at:

SMA Support, Inc.
P.O. Box 6301
Kokomo, IN 46904

Fax# 801-460-2813