All fields are required. Incomplete forms will not be considered. Requests for funding from the New York State Affiliate should not be considered all-inclusive and completing the Funding Request Form does not guarantee you will receive the funds you are requesting. While every effort will be made to provide assistance from the State Affiliate, these funds should be considered secondary to any assistance offered by your Chapter as well as your personal contribution. Requests for funding are due six weeks prior to the start of the event, unless an alternative deadline has been publicly announces. Expenses will not be authorized after the event takes place. Personal Information First Name * Last Name * Telephone * Email * Street Address * Please include Apt number. City * State * AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip * Five-digit code. Chapter/Division * - Select -Buffalo ChapterLong Island ChapterNew York City ChapterRochester ChapterSyracuse ChapterVanguard ChapterMember At-LargeGuide Dog Users DivisionParents Division In a few words, tell us about your activity with the Federation. * Event Information Event * - Select -Albany SeminarNational ConventionState ConventionWashington Seminar Have you requested funding for this event from your chapter? * - Select -YesNo - Please Explain Briefly Explain Why No Chapter Request Was Made Has the chapter made it’s decision regarding that funding request? - None -YesNo How much funding will you receive for this event from your chapter? $ State funding for National Federation of the Blind events will be granted up to three times annually for any individual. The only exception to this policy will be the current affiliate president or their designee, approved by the majority of the executive board. Have you received state funding for any other National Federation of the Blind event(s) this calendar year? * - Select -YesNo Which event(s)? Event Start Date * Please provide the start date of the event, including travel days. Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20242025 Event End Date * Please provide the end date of the event, including travel days. Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20242025 Travel and Accommodation Arrangements Sharing Room With * All lodging accommodations are based on, at least, double occupancy. Enter HELP if you need us to help you find a roommate. We will make every effort to assist. Request Details * (Detailed description of expenses you are requesting be covered.) Total Amount Requested * How much, in total, are you requesting? Enter only numbers with no cents. $ .00 Travel reimbursements are calculated for bus, train, or best-value airline, unless otherwise arranged in advance. The per diem rate is set at $60, to cover meals, incidental expenses, and ground transportation. Conditions and Agreement I understand that this request, if granted, may be fulfilled in whole or in part. I also understand these requests are due by a set deadline and requests received after that deadline may not be considered. Special circumstances may be brought to the President or the Executive Board for consideration on a case-by-case basis. I understand and agree to the following: If funding is granted for state or national convention, I agree to register, either online or upon arrival. If attending National Convention, I agree to attend the board meeting, the resolutions committee meeting, the six general sessions, our affiliate caucus and the banquet. If attending state convention, I agree to attend the board meeting, hospitality night, all three General sessions, and the banquet. I will represent the Federation with professional appearance and behavior at all times. I understand that I may be asked to support the affiliate in a variety of ways during the event for which I am requesting funding. This may include participating in fundraisers, marshaling, setting up events, etc. Receipts are to be provided within 30 days of the end of the event. Failure to provide receipts will disqualify me from future funding. Receipts for hotel and travel expenditures are required for reimbursement. Per Diem funding does not require receipts. Unused funds must be returned to the affiliate. Further, If state funding for the event is granted and subsequently, chapter funding is granted for the same expenses, the funding granted by the state must be returned. I Agree * I Agree I Disagree Electronic Signature * By typing your name in this box, and submitting this form, you agree to the requirements outlined above.