Personal Entity Enquiry Form You can download a form here, fill it out and return to us or alternatively fill in the form below and we will be in contact with you. REQUEST FOR FINANCIAL ASSISTANCE FOR PERSONAL APPLICATION Date:* Date:(1)*Section 1. Proposer Name of Applicant:* Relationship to Beneficiary:* Your preferred contact number:* Contact Email address:* Contact Postal address:*Section 2. Beneficiary Details Beneficiary’s name:* Beneficiary’s Date of Birth:* Beneficiary’s sex (M/F): * Beneficiary’s address:*Section 3. Beneficiary’s medical condition Please provide precise details of the Beneficiary’s medical condition and how our assistance will improve the Beneficiary’s life. (Wherever possible please provide your medical notes/report from treating doctor)* Upload a File:Section 4. Funding Purpose Please confirm that the proposed funding is for one or more of the following: Capital purchase (equipment/aides etc)MedicationRespiteSpeech pathologyMedical suppliesExpenses (insurance, contractors, repairers etc )OtherSection 5. Funding Purpose-specific Please provide details in relation to the purpose of the funding. (Please incorporate a breakup of the total costs relative to your request if appropriate ie :- Capital cost, installation, technical assistance, training costs or any ongoing service fees, if any. (It is important that we are aware of your total needs from the outset.)*Section 6. Funding Amount Please provide the total of the funding sought to complete your proposal (please include GST component): *Section 7. Supplier/SuppliersPlease give details of the proposed supplier of goods or services. Name:* Address:* Phone Number:* Email address:* Contact name (if known):(Note: Generally KKKK will pay against receipt of invoices, delivery of goods, or against completed medical services where appropriate)Section 8. Funding Timeline Please advise timing for funding (i.e. 1 mth,3 mths etc.) and whether funding will be required in one lump sum or will a deposit be required (if capital purchase ie wheelchair etc)*Section 9. Other parties Have you applied to any other organization either successfully or unsuccessfully for this funding ? if so please provide details and any written or verbal responses you may have received.*Section 10. Funding Reason Please give details of your reason for making application with “KKKK” for funding. We would particularly like to learn of any previous efforts to accommodate your needs and if any other local charities have assisted in the past. Please also advise how your current situation has affected you financially etc.*Section 11. GeneralIn normal course the KKKK committee will consider and provide a response to your request within a 30 day cycle from date of receipt. We may need to contact you should further detail be required. We also invite you to contact Tony Springett if you require any assistance in completing this request.Please also advise as to how you became aware of “KKKK”. Word Verification:SubmitReset
