Katherine Ann Swain Fund for Adult Survivors of Abuse and Neglect

Name*

Email*

Address*

Street Address City State ZIP Code

Phone*

Katherine’s hope is that her endowment will inspire, uplift, enrich and restore; and help adult survivors persevere. To that end, Katherine wishes to provide monetary support to help repair some of the damage done by abuse or neglect. Please share your survival story and how this grant will help you including how you will use these funds.*

Cost of Services*

Do you have medical/dental insurance*

Yes
No

Will your insurance cover the cost of services?*

Yes
No

Estimate from provider including portion covered by insurance (Please upload a pdf file)

For SCF use only: Notes

For SCF use only: Gave to Tara for Review

Yes
No

For SCF Use only: Approval

Approved
Denied

For SCF use only: Follow Up Report Received

Yes
No

Name

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Katherine Ann Swain Fund
for Adult Survivors of Abuse and Neglect

Katherine Ann Swain Fund for Adult Survivors of Abuse and Neglect (Individual)

Katherine Ann Swain Fund for Adult Survivors of Abuse and Neglect Donation

Katherine Ann Swain Fundfor Adult Survivors of Abuse and Neglect

Katherine Ann Swain Fund for Adult Survivors of Abuse and Neglect (Individual)

Katherine Ann Swain Fund for Adult Survivors of Abuse and Neglect Donation

Katherine Ann Swain Fund
for Adult Survivors of Abuse and Neglect