Emergency Family Assistance Application

Initial application for eligible U.S. citizens residing in Texas who are seeking help related to an individual living with profound autism.

Before you begin: This initial form does not request medical records, tax returns, Social Security numbers, or bank information. If your request moves forward, the Foundation will provide instructions for submitting supporting documentation securely.

1. Basic eligibility

All answers are required for initial screening.

The individual for whom assistance is requested is a U.S. citizen.The individual currently resides in Texas.The individual has documented profound autism or equivalent documented lifelong intensive support needs.If awarded, I agree to use funds only as approved and submit proof of expenditure.

2. Applicant information

Your full name *

Relationship to individual *

Email *

Phone *

Mailing address *

City *

ZIP code *

3. Individual with profound autism

Full name *

Date of birth *

Briefly describe diagnoses and daily support needs *

Current living arrangement

State-funded program, if any

ABLE account?

Special needs trust?

4. Funding request

Amount requested *

Primary request category *

Describe exactly how the funds would be used *

Why is this need urgent or not otherwise covered? *

Provider or vendor name, if known

Estimated total cost

Other funding, insurance, grants, or resources pursued

Previously received Foundation funding?

If yes, approximate date and amount

5. Financial need

Approximate annual household income *

Number of people in household *

Individual receives SSI?

Individual receives SSDI?

Briefly describe the financial hardship and how assistance would help *

6. Certification and consent

I certify that the information provided is true and complete to the best of my knowledge.I authorize the Foundation to request reasonable documentation and verify information needed to review this request.I understand that funds are limited and submission does not guarantee approval.If approved, I agree to use funds solely for the approved purpose, provide receipts or other proof of expenditure, notify the Foundation of material changes, and return unused or misapplied funds if requested.

Typed signature *

Date *