MAP Online Application

Monetary Assistance Program

Contact us for assistance with this application:

(859) 379-8230

info@biank.org

First name

Last name

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Name of person assisting with application (if applicable):

Has this request been funded elsewhere (ex: insurance, other non-profits, or donations)?

Yes

What is the total dollar amount of this request (not to exceed $300)?

Which category are you requesting the funding in?

Supporting Documentation:

Please review the requirements for your selected category Monetary Assistance Program and upload any necessary supporting documentation.

I certify that I am requesting funds to help supplement the costs (directly or indirectly) associated with my brain injury or the brain injury of the person I care for:

Signature

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Monetary Assistance Program

Contact us for assistance with this application:

(859) 379-8230

info@biank.org

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