FSSP Reserve Application

Have you accessed other sources of funding such as personal funds, Medicaid, Social Services, HCP, Shriner's. etc.:

If your request is funded, how will your family benefit?:

Briefly describe your need for funding at this time:

Child's Date of Birth *

Mailing Address : *

Parent(s)/Guardian(s) Name: *

FSSP Special Reserve Request Form

If YES, when and how much money did you receive?

AMOUNT REQUESTED:

Please describe the nature of your child's special needs:

Name of child in need of this fund: *

Please complete all parts of the form below, Check the agreement box, and click on the submit application button.

Check Box *

By checking this box, I hereby certify that to the best of my knowledge the above information is correct and I understand that I must provide receipts for purchased service or items.By checking this box, I agree to all statements in this application.

If YES, date you received funds

Have you accessed Special Reserve funds since July 1st? YES or NO:

Home Phone No.: *

FSSP Reserve Request Form

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call us :

(970) 259-2464

Community Connections, Inc.

Main office: 281 Sawyer Drive, Suite 200, Durango, CO 81303
Cortez office: 105 S Harrison, Cortez, CO 81321
P: (970) 259-2464 I F: (970)259-2618 I E: cci@cci-colorado.org

Office hours: M-Th 8am - 5pm

Access to a TDD system upon request

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