FUNDING APPLICATION To be compelted by referring professional Aftercare Coordinator | Therapist | Counselor Name Email Address Phone Number Facility Name Name Of Recovery House Recovery House Address Recovery House Address Line Two Recovery House City Recovery House State Recovery House Zip Contact Person Contact Person Phone Contact Person Email Weekly Cost Is accepting house aware intake fees/security deposits must be waived? Is accepting house aware intake fees/security deposits must be waived? Yes No Please Explain Need For Assistance Applicant Name Applicant Phone Applicant Email Applicant Last Known Address Applicant Last Known Address Line 2 Applicant Last Known City Applicant Last Known Zip Applicant Last Known County Employed Employed Yes No Have You applied to other organizations for financial assistance? If so please list below. Have You applied to other organizations for financial assistance? If so please list below. Yes No Resource Name Resource Contact Email Resource Name Resource Contact Email Resource Name Resource Email Certification that NO other financial assistance is being accepted from federal, state, county, friends, family or organizations other than the Leigh Leckerman Foundation. Certification that NO other financial assistance is being accepted from federal, state, county, friends, family or organizations other than the Leigh Leckerman Foundation. Yes Signature 12 + 11 = SUBMIT *Please be advised NO funding will be granted without a completed and approved application.