Next Application Deadline
SEPTEMBER 21, 2010

FAQ Information
 
Submit an Online Application 


Haiti's Families in Need
    AutismCares is investigating how  to best help families affected by autism in Haiti. We will keep you updated as we learn more.

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AutismCares helps families affected by autism to cover costs associated with critical living expenses; housing, utilities, car repair, daycare, funeral expenses, and other items on a case-by-case basis.

Eligible families have:

  • A child (children) diagnosed with autism
  • Income of $65,000 or less
  • Experienced one of the following qualifying events in the preceding 90 days:
    • Natural disaster: fire, flood, hurricane, tornado, severe storm or earthquake
    • Death or critical illness in the immediate nuclear family
    • Victim of a violent crime
    • Loss of home through foreclosure or eviction
    • Termination of employment of primary income-earner

 
Marital Status
 
 
First Name
 
 
Last Name
 
 
Mailing Address
 
 
City
 
 
State
 
 
Zip Code
 
 
Email Address
 
 
Phone Number
 
 
Alternate Phone Number
 
 
Please Choose a Qualifying Event:

Natural disaster:
 N/A
 Fire
 Flood
 Hurricane
 Tornado
 Severe Storm
 Earthquake
 
Date of Qualifying Event (DD/MM/YY)
 
 
Death or critical illness in the immediate nuclear family
 Yes
 No
 
Family member with illness
 
 
Diagnosis or cause of death
 
 
Violent crime
 Yes
 No
 
Type of crime:
 
 
Was a police report filed?
 Yes
 No
 
Loss of home through foreclosure, eviction or natural disaster
 Yes
 No
 
Date of notice:
 
 
Termination of employment
 Yes
 No
 
Family member who lost job:
 
 
Was this person the primary income earner?
 Yes
 No
 
Reason for termination?
 
 
Are you receiving unemployment or other benefits?
 Yes
 No
 
Date of Qualifying Event (DD/MM/YY)
 
 
Family Information:

List all Family Members Affected by Autism (Name, DOB, Diagnosis)
 
Financial Information:

Annual Household Income
 
 
Federal/State Assistance
 
 
Total Monthly Expenses
 
 
Person Completing Application
 
 
Date (DD/MM/YY)
 
 
Request a Family Support Award:

Amount of Request
 
 
Please use the space below to describe your financial need.
 
List specifically how the funds will be used, include vendors and amount.
 
What will the impact of these funds be on your situation?
 
How did you hear about AutismCares:
 Internet
 
What site?
 
  Friend or Family Member
 Autism Organization
 State or Federal Agency
 Other