Name of Applicant:   

Address:                   

City:                         

State:                       

Zip Code:                

Telephone:               

Status:                      
Please list either "Blind MCB Member", "Sighted MCB Member", or "Blind non-MCB Member":

(Blind non-MCB members must submit verification of blindness–letter on official letterhead from doctor, state or private agency.)   

Income:  Source of household income: 

Number of persons in household:         

Total amount of household income:      

Amount of Grant requested:  

Reason why you cannot pay said expenses: 
(If due to property loss, money or check loss or theft, please submit a copy of police report, if possible.)     

What other attempts have you made to acquire funds?  

Name of person or group referring you: 

E: Signature of Applicant: 

F: Date submitted:           

An application must be processed within
thirty days of the application being received
by the Committee chairperson.

C.  Application - Please list "Approved" or "Denied"  

3.  Reasons for denial, if denied:   

D.  Signature of Committee:  

Chairperson:  

E.  Date Approved or Denied: 

Name:     

Address:  

Phone:     

To provide the Missouri Council of the Blind with requested information regarding my: 

*The committee chairperson is to list either "Scholarship needs", "Status of health", or "Emergency needs.":

Date: