Comstock Quality of Life Grant Reimbursement Form
Please review the updated
Quality of LIfe 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 select...
Communication tools (Smart phone, iPad, writing board, computer software, apps, etc.)
Transportation including unreimbursed travel to participate in FTD research (taxi, accessible van, etc.)
Companion care
Insurance co-pays, medication costs, or therapies (occupational, physical, speech, or counselingservices)
Home adaptations
Gym membership or exercise class
Grooming and cosmetics (Haircuts, manicure/pedicure etc..)
Other
Please use keyboard CTRL + mouse button to select all options that apply.
Is a receipt available?
Yes
No
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.