DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Public Health F-01264 (06/2017) SERVICE FUND APPLICATION FOR REIMBURSEMENT Organizations please complete Section 1 only. Directions: Deaf and Hard of Hearing people please complete Section 2 only. Send completed form as indicated below TWO WEEKS PRIOR TO THE EVENT. For More Information about Service Fund Requirements go to: SECTION 1 ORGANIZATIONS OR AGENCIES – Agency/Organization Name Applicant’s Full Name If Affiliated with a Parent Organization List Name – Street Address City State Zip Code WI Contact Phone Number Contact Email Address - - List Service(s) Your Agency/Organization Provides Reason You are Requesting Financial Assistance Financial Structure of Your Organization (i.e., justification of an undue hardship) List Brief Description of Service You are Providing for the Deaf or Hard of Hearing Consumer(s) Service(s) Being Provided Date Time Location Type of Service You are Requesting (e.g., two interpreters for eight hours) Cost Estimate for the Service SECTION 2 DEAF & HARD OF HEARING CONSUMERS – Name Phone number Applicant’s Full Applicant’s Email Address Applicant’s Reason for Interpreter/CART/SSP Date Time Information contained in email messages may be privileged and confidential. There is some risk that any information in an email you send may be disclosed to, or intercepted by, unauthorized third parties. By agreeing to allow the use of email as a method of communication to WI DHS, this indicates that you acknowledge and accept the possible risks associated with such communication.
DEPARTMENT OF HEALTH SERVICES Division of Public Health F-01264 (06/2017) STATE OF WISCONSIN SERVICE FUND APPLICATION FOR REIMBURSEMENT Directions: Organizations please complete Section 1 only. Deaf and Hard of Hearing people please complete Section 2 only. Send completed form as indicated below TWO WEEKS PRIOR TO THE EVENT. For More Information about Service Fund Requirements go to: SECTION 1 – ORGANIZATIONS OR AGENCIES Applicant’s Full Name Agency/Organization Name If Affiliated with a Parent Organization – List Name Street Address City State Zip Code WI Contact Phone Number Contact Email Address - - List Service(s) Your Agency/Organization Provides Reason You are Requesting Financial Assistance Financial Structure of Your Organization (i.e., justification of an undue hardship) List Brief Description of Service You are Providing for the Deaf or Hard of Hearing Consumer(s) Service(s) Being Provided Date Time Location Type of Service You are Requesting (e.g., two interpreters for eight hours) Cost Estimate for the Service SECTION 2 – DEAF & HARD OF HEARING CONSUMERS Applicant’s Full Name Applicant’s Phone number Applicant’s Email Address Reason for Interpreter/CART/SSP Date Time Information contained in email messages may be privileged and confidential. There is some risk that any information in an email you send may be disclosed to, or intercepted by, unauthorized third parties. By agreeing to allow the use of email as a method of communication to WI DHS, this indicates that you acknowledge and accept the possible risks associated with such communication.