Family Grants Application Form

Please fill out all required fields and be sure to send in the required supporting documents. Applications cannot be considered until all required paperwork is received.

You can fill out the application below and submit it online or print it out (right mouse click>select print) and mail it to:

Asperger/Autism Network (AANE)
51 Water St., Suite 206
Watertown, MA 02472

Please feel free to call the AANE Family Grants Administrator, at 617 393-3824 x241 if you have any questions regarding the application process.

Family Information
First name parent/guardian*
Last name parent/guardian*
Street address*
City*
State*
ZIP Code*
Primary phone*
What type of phone number is this:
- Mobile
- Landline
Email address of parent*
Information About the Child with an Asperger/autism profile
First name of child with an Asperger/autism profile*
Last name of child with an Asperger/autism profile*
Birthdate*
MM slash DD slash YYYY
Grade in school (if applicable)*
My child has the following diagnosis:*
My child lives more than half of the time with one or both parents in a home in CT, MA, ME, NH, RI, or VT.*
- Yes
- No
Request for Funds
Amount requested:*
What will you use the funds for?*
Please enter any additional information or special circumstances that you wish to add to your request for a grant
What documentation of diagnosis will you be mailing to AANE
- Neuropsychological or psycho-educational testing report
- IEP
Documentation is required as part of this application
Family Financial Information
As soon as possible, you need to provide documentation of your total family income for the most recent year.
We cannot process incomplete applications (ones lacking documentation of diagnosis and of income).
Enter the total of your family’s pre-tax income from all sources.*
Please select which form(s) of documentation you are mailing to AANE
Documentation of Federal Tax Returns*
- I am mailing/emailing a copy of page one of my most recent federal tax return, showing total family income (earned and unearned) before taxes.
- I am not required to file a tax return and do not file.
Documentation of SSI payments received for yourself or your child's other parent/guardian.*
- Yes
- No
Documentation of SSI payments received for your child*
- Yes
- No
Documentation of Transition Assistance payments received*
- Yes
- No
Have you received family support funds this year from any other agency?*
- Yes
- No
The Check
Please enter the name and mailing address where the check should be mailed
The check should be made out to:*
Street address*
City*
State
ZIP Code*
Additional Required Materials (Documentation can be mailed to AANE)
Asperger/Autism Network (AANE)
51 Water St., Suite 206
Watertown, MA 02472
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Main Office 51 Water Street, Suite 206, Watertown, MA 02472

(617) 393-3824

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Family Grants Application Form

Family Information

Information About the Child with an Asperger/autism profile

Request for Funds

Family Financial Information

Please select which form(s) of documentation you are mailing to AANE

The Check

Additional Required Materials (Documentation can be mailed to AANE)