Special Services Application – Missouri Council of the Blind

Personal Data

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Visual Status

Totally Blind
Legally Blind
Sighted

Membership

Are you a member of MCB? If not a member of MCB, applicant must submit verification of blindness (letter on official letterhead from doctor, state or private agency.)

Yes
No

Application Information

Number of persons in household:

Amount of Grant Requested?

Reason you cannot pay said expenses:

Other attempts have to have been made before you apply for this grant. What other attempts have you made to acquire funds?

NOTE: If approved, all attempts will be made to make a check payable to the third party.

SUPPORTING DOCUMENTS

A signed release of information form must accompany your application
Utility Bill: If request is for utility payment
Other Bills: If other than utility, include bill with account number or customer ID
Purchase: For purchases, include name of business, business address, phone number and price quote on Company letterhead.

Submit this electronic Application and mail Supporting Documents to:

Missouri Council of the Blind

5453 Chippewa Street

St. Louis, MO 63109