Grant Application – Oregon Special Needs Trust

I am completing this request: *

for myself (applicant)

for someone else (requestor)

Grant Requested *

Final Expense Grant

Legal Expense Grant

Accessibility Grant

Convention/Conference Grant

Education Grant

Amount of Request *

Please enter the dollar amount being requested.

Payment Method *

Mail check to vendor or service provider

Call vendor or service provider to make credit card payment

Complete online purchase

How would you like us to disburse the grant award funds?

PAYEE INFORMATION

Grant awards will only be paid directly to a vendor or service provider. Provide payee information for grant fund disbursement.

Vendor/Service Provider Name *

Payment can NOT be made payable to the trust beneficiary or family member.

Vendor/Service Provider Phone Number *

Mail Check To: *

Name

Address *

Address

City

State/Province

Zip/Postal

Country

ONLINE PURCHASE INFORMATION

Is the online purchase for a physical item that will need to be shipped, such as a piece of adaptive technology or durable medical equipment? *

Yes

Website *

Copy and paste the website URL that you would like us to use to complete the purchase.

Purchase Details

I have created a shopping cart with the items that I want to buy

I will list the items I want to purchase below

Shopping Cart User Name

Password

How would you like to receive the items being ordered? *

Pick up at the store

Shipped

Store Name

At which store would you like to pick up your items?

Store Address

Shipping Address

City

State/Province

Zip/Postal

Country

Items to Purchase

Please enter information on the items you would like to purchase. You may add additional items (up to 10 total items) by clicking the Add Item button.

Item Description

(include item stock number, size, color, etc)

Item Cost

Special Instructions or Comments

Add Item Remove Item

REQUESTOR INFORMATION

Name of Person Submitting Request *

First

Last *

Last

Phone Number of Person Submitting Request *

Email of Person Submitting Request *

SPAM Prevention

Remainder Fund Grant Application

APPLICANT INFORMATION

PAYEE INFORMATION

ONLINE PURCHASE INFORMATION

Items to Purchase

REQUESTOR INFORMATION