Autism Hope Alliance(AHA)
Financial Aid Application

• Complete the ATEC survey and save a copy of the results to be uploaded into the application –
http://www.surveygizmo.com/s3/1329619/Autism-Treatment-Evaluation-Checklist-revised

• Confirm that you do not make more than the median income for your county.

http://www.energyjustice.net/justice/index.php?gsLayer=income&gfLon=95.3&gfLat=39.6&giZoom=4&

Scan a copy of your most recent tax return (multiple returns if more than one income and not filing jointly) to be uploaded into the application

Scan a copy of your diagnosis form from your healthcare provider to be uploaded in the application.

Scholarship applications will be reviewed and prioritized by the order in which they are received.

PLEASE COMPLETE A SEPARATE FORM FOR EACH PROGRAM PARTICIPANT





Annual Household Income



Please share your reasons for applying for financial aid (if needed, us additional paper):

All information submitted to AHA shall remain confidential. Please note that, pursuant to federal law requirements, AHA reserves the right to follow up to ensure any approved grant was actually used for its intended purpose.

I certify that the information on this form is true and complete to the best of my knowledge.

I understand that if I receive this financial aid and will use it exclusively for my child with a diagnosis of Autism.

By my signature (or e-signature) below, I hereby declare the above statements are true and correct to the best of my knowledge. I have clear and convincing documentation of all above statements and can provide these documents upon request of the AHA Financial aid Program. My signature below also confirms that I understand the eligibility and requirements of this scholarship and it will be reviewed on a yearly basis.

Signature________________________