Grant Application Call (313) 744-3488 for questions or help with this form. Contact Information First Name: Last Name: Address 1: Address 2: City: State: Zip Code Contact Preferences Phone Number DaytimeEvening E-Mail Address Purpose of Item being requested Health or Self-careCommunicationProductivityOther Other Catagory Item Description Below, please provide a description of the item you will be purchasing. The reason for the item and how it will increase your independence. The cost, place of purchase, and include a link to the item if possible. Someone from the committee will contact you within 30 days. Thank you. Item Description and other comments:
