FORM ONLY – Individual Grant Request

Individual Grant Request

For residents in the mid-Atlantic region (PA, NJ, MD, DE, DC, or NY)

This field is for validation purposes and should be left unchanged.

Applicant Contact Information

Applicant Name(Required)
Home Address(Required)
For residents in the mid-Atlantic region (PA, NJ, MD, DE, DC, or NY)

Applicant's Annual Income

Household Members' Annual Income

Dependent Information

Dependents
Name
Age
 
(NOT already listed)



I acknowledge that the information provided is true and correct. I authorize the facility to verify any information contained in this document for the sole purpose of assessing financial need. I understand that if my financial situation or availability of resources changes, I am required to notify the facility of the change for the purpose of being reassessed for this grant.
Clear Signature
Signature of Applicant

Additional Documentation

Income Verification
  1. Most recent year of Income Tax Returns (for all household members) – 1040 or 1040EZ, as filed with the Internal Revenue Service
  2. Two most recent consecutive pay stubs (for all household wage earners), showing gross and net income (if applicable) OR
  3. Letter of employment on company letterhead with Applicant’s full name, specified salary (gross), signature of employer representative with title, contact number, and date OR
  4. Disbursement letter from Social Security Office for annual income verification.
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    Letter of Inquiry
    1. Candidate biography and description of physical, cognitive and/or behavioral challenges
    2. Specific type of grant request (equipment, training, program, etc.)
    3. A brief statement (two or three sentences) of the purpose for your request, including what level of athlete you consider yourself – beginner, intermediate, advanced or elite.
    4. How an IM ABLE grant award will help serve your above stated purpose
    5. Describe how an IM ABLE grant will help you meet the stated mission of the IM ABLE Foundation
    6. Describe the financial hardship that qualifies you for Foundation support, including a statement of annual income and/or a list of your sources for financial support. Please include the number of individuals in your household.
    7. Describe your willingness to serve as an IM ABLE “Ambassador” at the Foundation’s racing events, fundraisers and community events.
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      Three letters of reference (2 Personal, 1 Medical)
      1. 2 Personal Letters of Reference – The signed letter will include the full name of teacher, peer, coach, family member, or friend with a statement along with an accurate phone number and email address. The letter should include why you are a good candidate for a grant and how they believe it would enrich your life.
      2. One Letter of Reference from a medical professional (doctor, physical therapist, occupational therapist, etc.) – The letter must be on letterhead and must be signed by the medical professional.
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        IM ABLE considers the following criteria when evaluating each grant application:
        • Commitment to the IM ABLE Foundation’s mission
          • The mission of the IM ABLE Foundation is to remove obstacles that prevent people with physical, cognitive, and/or behavioral challenges from being physically active by providing grants, resources, fitness opportunities and motivation.
        • Explanation of the financial need and/or hardship
        • Explanation of how this grant will provide additional opportunities to enrich the life of the applicant
        • Willingness of the grant applicant to act as an ambassador for the IM ABLE Foundation by “Paying it Forward”
        The Foundation’s Response

        We will send you an acknowledgment that your letter of inquiry was received through email, and we will direct it to the appropriate staff members for review. If, as a result of that review, the Foundation concludes that there is no prospect of IM ABLE funding, we will notify you promptly. Inquiries eligible for grant support will be acknowledged upon receipt at the Foundation; and the formal review process for eligible inquiries will begin. Grant applications are reviewed by the Board of Directors on a quarterly basis. Applications can be submitted four times a year with the following deadlines: February 1st , May 1st , August 1st , November 1st
        If approved for a grant, you will be required to do the following:
        • IM ABLE will forward a letter of agreement which you will be required to sign and return before grant can be completed.
        • Participate or attend a minimum of three events for one year, following your grant presentation. IM ABLE will consider the equipment on loan to the grantee during the first year. At the end of the first year, IM ABLE and the recipient will decide whether to transfer ownership permanently.
        • Use your grant in accordance with the letter of agreement.
        • Submit an impact statement and photo or video within three months of receiving your grant, as stated in the letter of agreement.
        • Represent IM ABLE and its mission in a positive manner and in accordance with the letter of agreement.
        • Participate in annual IM ABLE survey regarding the impact of the program on your physical activity.

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