FUNDING APPLICATION

To be compelted by referring professional

Is accepting house aware intake fees/security deposits must be waived?

Employed

Have You applied to other organizations for financial assistance? If so please list below.

Certification that NO other financial assistance is being accepted from federal, state, county, friends, family or organizations other than the Leigh Leckerman Foundation.

12 + 11 =

*Please be advised NO funding will be granted without a completed and approved application.