Application for Financial Assistance
At the Spina Bifida Coalition of Cincinnati, we understand that the unexpected costs of living with spina bifida can sometimes exceed your budget. To assist in meeting these emergency expenses, we offer up to $300 each year to help with medical, housing, utilities and other critical expenses. Please let us know in the comment section below if payment is necessary to avoid eviction or service disruption (please provide as much notice as possible). Although we try to accommodate everyone, financial assistance is limited and offered on a first-come, first-served basis, annually.
This form must be submitted with supporting documentation (invoice or bill) prior to payment. Payments will only be paid to provider, not the individual. Invoices can be emailed to firstname.lastname@example.org or faxed to 513-914-4931. An acknowledgement will be sent to you when payment is made.
By submitting this application, I certify that all the information provided is true and correct. I certify that the items listed are for the benefit of applicant. If any information is intentionally false, I agree to reimburse SBCC all costs, legal and otherwise, to recover disbursed funds.
Name Address Line 1, Address Line 2 City, State Zip Code Cell Phone Contact Email
Thank you for submitting your Application for Financial Assistance. Please allow 3 business days for processing. You will be notified when payment has been processed.