CDDO Funds Request Form- Provider Request version

Date of Request: Click here to enter text.

Person Submitting the Request:

Last Name: Click here to enter text.	First Name: Click here to enter text.
Address: Click here to enter text.	City: Click here to enter text.	State: Click here to enter text.	Zip: Click here to enter text.
Phone: Click here to enter text.	Email: Click here to enter text.

Signature: _____________________________________________________________________

Agency Director Signature/Date: ___________________________________________________

Identify the category of this request and describe what is being requested

☐ Agency Requests

☐ Other Requests

What dollar amount is being requested/identify specifics of the cost of the item/event or service:

Click here to enter text.

Will this amount cover the entire need or will other financial resources be necessary? Explain:

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Please outline the reason for the request for funds. Identify the target population and the goals and expected outcomes for the project/request. What other options have been explored for funding? Click here to enter text.

What other resources are available or have been pursued and either utilized or denied: (donations, foundations, organizations, etc.) Identify specifically. Demonstrate exploration/exhaustion of community resources.Click here to enter text.

Attachments for further documentation may be submitted with the request.

Additional information, clarification and documentation may be requested by the CDDO and/or committee.

Where necessary or appropriate bids from more than one provider source deemed may be requested.

CDDO’s preference is to pay the amount directly to the provider who is recognized or certifies for the service being provided. Documentation that the service was provided will be required.

Other follow-up may be requested as determined appropriate.

Funds review will be completed by the Funding committee in accordance with the Local Finance Plan. State Aid funds utilization must meet I/DD Taxonomy Code requirements. The intent is for all funds to be used to benefit services for developmentally disabled individuals in Cowley County. All requests will be reviewed and considered by the CDDO to assure appropriate and fair utilization of funds available and accountability. All requests will be reviewed but may not necessarily be approved. There is no assurance or entitlement related to these funds.

Funding Committee Determination as necessary: (date)Click here to enter text.

CDDO Action Determination: (date)Click here to enter text.

What Follow-up is expected?Click here to enter text.

Follow-up status:Click here to enter text.

CDDO Director Signature: ___________________________________________DateClick here

Date of review and signatures of others present: ______________________________________________________________________

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