Name: Friends of JCDS
Address: 10501 lackman road, Lenexa, KS, 66219
Telephone: 9138262270

Special Assistance Application

Step 1 of 2

Does the person making the request receive any direct services (case management, residential, or day/employment services from Johnson County Developmental Supports)?*
- Yes
- No
Thank you for your inquiry. Based on your response, it does not appear that your request would qualify for Special Assistance Funding from Friends of JCDS. Currently, all requests for Special Assistance must be made by an individual or their representative that receive at least one of the following: Targeted Case Management, Day/Employment Services or Residential Services from Johnson County Developmental Supports.

Today's Date*
Date Format: MM slash DD slash YYYY
Is this an individual or group request?*
- Individual
- Group
Name(s) of individual(s) needing assistance:*
JCDS Services Provided:*
- Targeted Case Manager
- Day Services/Employment
- Residential
Friends home:*
- Yes
- No
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Date Needed*
Date Format: MM slash DD slash YYYY
Amount Requested:*
Name of individual completing form:*
Email*
Contact name for questions and notifications:*
First Last
Phone*
In a brief paragraph please describe need for request:*
Please provide expected outcomes and goals will result from the request: (For example: Joe will start a walking program and has a goal of walking 1 day per week to improve health. OR After Sally has dentures, staff will work to support her in learning how to care for her dentures and necessary oral hygiene.)*
Other resources requested and result: Please provide copies of letters/emails declining support. Please note if the individual has a special needs trust. If the individual has a payee or conservator, please provide proof that the individual does not have funds available, this can be in the form of a bank statement. This is required. Application will be rejected if information is not provided.*
File- Please scan all documents into one file and upload
Financial resources of individual(s):

Additional documentation would help to facilitate our review. Please provide additional documentation to support request, such as copies of leases, recent copies of client obligation, etc.)
Friends of JCDS Special Assistance Request Budget Form
Monthly Income
JCDS Payroll Earnings:*
Other Employment Earnings:*
SSI:*
SSDI:*
Food Stamps:*
Rental Assistance:*
Other:*
Total Income:*
Monthly Expenses
Rent:*
Utilities:*
Transportation:*
Groceries:*
HCBS Obligations:*
Personal Care Expenses:*
Spending Money:*
Other:*
Total Expenses:*
Provide additional instructions necessary to fulfil request: (Payee, address, phone number, additional contact information, etc.)*
Amount the individual can contribute:*
Does the person making the request receive any direct services (case management, residential, or day/employment services) from Johnson County Developmental Supports?*
Please complete form in its entirety. Friends of JCDS, Inc. may have additional questions regarding this application and should you be contacted, please respond promptly. Requests for additional information that are not responded to within 2 business days will result in denial of the request. Individuals must receive services from Johnson County Developmental Supports in order to qualify for support from Friends of JCDS, Inc.
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Special Assistance Application

Step 1 of 2

Friends of JCDS Special Assistance Request Budget Form

Monthly Income

Monthly Expenses