General Assistance Fund

PURPOSE:

PWSA of WI, Inc. wishes to provide financial assistance in order for families of a person with PWS to help meet the unique needs of these individuals and their families.

ELIGIBILITY:

Eligibility is based on financial need. Financial need being equal, the second consideration would be given to those who could benefit most from funds (respite intervention or personal/behavioral issues that need to be addressed).

  1. Any person with PWS who resides in the state of WI.
  2. The person with PWS or the caregiver or a family member of the person with PWS must be a member of the state chapter of the PWSA of WI, Inc.

Name of person with PWS*

Sex*
 Male Female

DOB*

Address*

City*

State*

Zipcode*

Is individual, family member or caregiver a member of PWSA of WI, Inc?*
 Yes No

Does individual reside in WI?*
 Yes No

Does a parent/guardian reside in WI?*
 Yes No

Email address*

Home phone*

Work phone*

Cell phone*

Parent/guardian’s or Person with PWS’s employer if not residing at home*

Current position*

Employer’s address*

Dates at present job*
to:

Gross annual income (select one)*
 < $15,000 $15,000 - $29, 000 $30,000 - $41,000 $42,000 - $59,000 $60,000 - $119,000 over $120,000

Average monthly amounts of other income (Please specify sources, ie. SSI, SSDI, MA, CIP)*

Specific dates funds are needed by*

Amount requested*

What will funds be used for?*

Why would this scholarship be helpful to you?*

How will funds improve the quality of life for the individual with PWS? (Financial need, need for respite, etc.)*

I certify that all of the information given above is true and correct. I understand that any false or incomplete statements in this application may make this application ineligible for funding. I authorize verification of any of the above information.

I accept*

*Required field