Minnesota Rehabilitation Association
Client Assistance Request Form
Sign in to Google to save your progress. Learn more
Client Assistance Request Form
Purpose: To provide financial assistance to participants receiving support from an MRA Member, in order to reach employment or educational goals.

Guidelines:
• Funding requests come from MRA member
• Up to $150.00 per request (including shipping if needed)
• Limit request for participant to 2 times per year, beginning with the date of first request
• Requests to be approved or denied by Participant Fund Team


Process:
• Complete application
• Participant Fund Team will review and respond to request within 3 business days
• Reimburse MRA member by check
• If direct purchase is requested MRA will purchase and ship item to MRA member


If an answer does not apply please respond N/A.

MRA Member Name *
MRA Member Number *
MRA Member Email Address *
MRA Member Phone Number *
Participant First Name and Last Initial *
Identify Request and Explanation/Description *
Amount Requested *
MRA Member Reimbursement FULL Address for Check (please include city, state, and zip code) *
Check Should Be Made Out To: *
MRA to Purchase Item Directly *
Website for Item Purchasing *
Description of Item Purchasing *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms