Application Form for Funding Assistance

Before you proceed with the application, please read the Community Health Outreach Project Guidelines for Funding Assistance. Have your supporting documentation (as noted in the guidelines) saved on your computer so it can be easily uploaded. You will NOT be able to save your application form and return to it at a later date.

If you prefer to print a hard copy of the form, click here.

The Project provides funding for the purchase of equipment, services, supplies, and other supports needed by persons with disabilities when other funding options, such as Medicaid, government programs, private insurance, and other foundations/grants, have been explored and deemed unavailable. Opportunities for funding include, but are not limited to: Assistive Technology, Durable Medical Equipment (DME), Enhancements to Durable Medical Equipment (DME), Medical Supplies, Repair Services for Equipment and Vehicles, and Specialty Care and Evaluations..

Eligibility Requirements

To be eligible for consideration of funding:

1) The recipient must reside within New York State.
2) The item/service purchased, or to be purchased, must fall within the Project time period, which is January 1, 2022 through December 31, 2022.  Direct cash assistance is not provided under any circumstances.  Therefore, you cannot be reimbursed for payments already made to suppliers, contractors, agencies, physician offices, etc.3) The total Household Income must be at or below 200% of the 2021 federal poverty level to qualify, which is:

  • $25,760 or less for a family of 1
  • $34,840 or less for a family of 2
  • $43,920 or less for a family of 3
  • $53,000 or less for a family of 4
  • $62,080 or less for a family of 5
  • $71,160 or less for a family of 6
  • $80,240 or less for a family of 7
  • $89,320 or less for a family of 8
    Add $9,080 for each person over 8 family members.


Payments through this Project will be made directly to their sources such as, suppliers, contractors, agencies, and physician offices/clinics, as noted in your application and supporting documentation.  This Project will fund services rendered or equipment/supplies to be purchased during the Project period, which is January 1, 2022 through December 31, 2022.  Funds will not be provided for anything prior to January 1, 2022.  

Direct cash assistance to applicants is not provided under any circumstances.  Therefore, you cannot be reimbursed for payments already made to suppliers, contractors, agencies, physician offices, etc.

Funding Limitations

This Project has a limited amount of funding to award during the year.  Therefore, applications will be handled on a first-come, first-serve basis.  All completed applications will be considered by the Awards Committee provided funding is still available at the time of receipt of application.  There is no guarantee of funding or approval of your request.  Please note that individual awards rarely exceed $5,000, and the average awarded amount per person per year is approximately $3,500.  Only one application for one item or one service can be submitted for a recipient during the year.

Supporting Documentation

In order to be considered for funding, appropriate documentation must be submitted with your application form.  Since payment will be made directly to its source, you must provide appropriate, written documentation validating your request.  Examples include, but are not limited to:

  • An invoice from a physician office/clinic that requires payment for services rendered.
  • A Contractor’s estimate for work to be performed along with the timeline for completion of the project. CP of NYS will work with the Contractor to assure timely work is completed so that corresponding payments can be made.
  • A complete description, including manufacturer, model number, and cost of the item/equipment to be purchased, along with where the item/equipment will be purchased. CP of NYS may choose to order the item/equipment directly from a supplier and have it shipped directly to the Recipient’s residence.

In all instances, you must indicate why Medicaid/Medicare/Insurance Plan would not cover the cost for the requested service or item, unless you have absolutely no insurance options.

Consent to Release Information and Affirmation

All applicants must consent to release information to CP of NYS for verification purposes and affirm that all information furnished in the application form and supporting documentation is true and accurate.  An electronic agreement is required at the end of this form ensuring you have sought funding through all other channels, but your request cannot be covered, either partially or fully, by Medicaid or any government program, commercial insurance, or other possible funding mechanisms.  Unsigned forms will be ineligible for funding.

Award Process

Applications will be reviewed on a monthly basis by the Awards Committee.


For further information or if you have any questions regarding the Community Health Outreach Project, please contact:

Cindy J. Morris
Project Director
Cerebral Palsy Associations of NYS, Inc.
Phone:    (518) 612-4510