Grant Request Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Current Appointment * Applicant Status * Clergy Spouse Dependent Child If Clergy Active, Full-Time Active, Part-Time Retired Health Insurance * Conference Active Conference Retired Other If Other, Describe Number of Persons Living in Household * Other Dependents * If other are supported, explain: Out of Pocket Expenses For: * Doctor Hospital Dental Prescription Eye Other Summary of Expenses (List Amounts) * After your application is preliminarily reviewed, you will receive a DropBox File request to submit documentation of out of pocket expenses. Health Savings/Health Reimbursement Available * $ Statement of Non-Medical Financial Need Please list any non-medical expenses for which you are seeking grant support Net Expenses Submitted for Consideration * $ Estimated Annual Household Income * After your application is preliminarily reviewed, you will receive a DropBox File request to submit documentation of household income. $ Other Comments Thank you for your grant submission. If you have further questions, please contact Rev. Mark Weatherman, PRS Treasurer, at pastormark6984@gmail.com or (419) 889-7951.