Comstock Respite Grant Reimbursement Form

Please review the Respite Grant Guidelines before filling out this form. If you have any questions, please contact comstockgrants@theaftd.org.

You can request one (1) reimbursement per grant.

Grant Recipient First Name:

Grant Recipient Last Name:

Email:

Grant Reference ID:

20 Max Characters

Type of service or expense:

Please use keyboard CTRL + mouse button to select all options that apply.

Name of Service/Respite Provider

If you did not use the grant for respite care, please enter N/A

Is a receipt available?

YesNo

First Date of Service

AFTD cannot reimburse expenses incurred before the date a grant was awarded.

Last Date of Service

Total Hours of Respite. Estimate the hours of respite care/other services this grant provided you. If you did not use the grant for respite or other services enter 0 (zero).

Total Requested Reimbursement.

Please briefly describe how you used this grant:

Certification

Yes, I certify that the information is correct to the best of my knowledge.