IASF, Inc.
815 John St.
Suite 210G
Evansville, IN 47713
Application Code No. ____________
(For office use only.)
812-202-9405
IASF Application
Thank you for completing the IASF Voucher Program application. This program is
designed to provide a financial voucher award paid to the provider of autism-related
products or services identified by the award recipient. The voucher award will not be
paid to the recipient directly. For us to consider your need, this application must be
filled out completely and honestly.
Caregiver Information
First Name of Parent / Legal Guardian
Last Name of Parent / Legal Guardian
Address
City, State ZIP
County of Residence
Email Address
Daytime Phone Number
Evening Phone Number
Number of people living in your household
Annual Insurance Deductibles
Individual
Family
Adjusted Gross Income (as reported on You can view your AGI on your
your IRS 1040)
last year’s tax return. Here’s where to find
it:
Please check one:
□ $125,000 or less
□ $100,000 or less
□ $75,000 or less
□ $50,000 or less



IRS 1040 – Line 37
IRS 1040-A – Line 21
IRS 1040-EZ – Line 4
Child Information
First Name of Child
Last Name of Child
Date of Birth / Age
Gender
DOB
Age
Boy
Previous Services
Girl
Current Services
Has your child participated in previous
intervention services?
Is your child currently participating in
intervention services?
□ Yes
□ Yes
□ No
□ No
If yes, please check all that apply:
If yes, please check all that apply:
□ First Steps
□ First Steps
□ School (preschool/special education)
□ School (preschool/special education)
□ ABA (Applied Behavior Analysis)
□ ABA (Applied Behavior Analysis)
□ Occupational Therapy
□ Occupational Therapy
□ Physical Therapy
□ Physical Therapy
□ Speech-Language Therapy
□ Speech-Language Therapy
□ Other (please list)
□ Other (please list)
Does your child have health insurance?
□ Yes □ No
If yes, please check all that apply:
□ Primary
□ Secondary
□ Tertiary
□ Medicaid
□ Medicaid Waiver/Voucher
Impact of Autism Spectrum Disorder
What is your best estimate regarding the
impact of your child’s autism spectrum
disorder in their daily life?
□ Minimal
□ Mild
□ Moderate
□ Severe
Is this the 1st time you’ve submitted an
IASF voucher application for this child?
□ Yes
Has this child received a previous IASF
voucher award?
□ No
□ Yes
Amount Requested (maximum = $650)
□ No
Use of Funds
Please specify the amount you are
requesting:
Please specify how the voucher funds
would be utilized:
□ Full amount = $650
□ Continue with a current service or
product.
□ Partial amount = _______________
□ Initiate or resume a previous service or
product.
Please provide specific information regarding the service or product you will utilize.
Service Provider Information
Product Information
Name:
Name of
Product:
Name of
Company:
Address:
Address:
Phone:
Phone:
e-mail:
e-mail:
if available
if available
Cost of
Service:
Cost of
Product
Health insurance coverage of this product
or service.
□ n/a (My child does not have insurance.)
How did you learn about the voucher
program?
□ IASF website
□ Insurance covers the full cost.
□ e-mail
□ Insurance covers half of the cost.
□ Insurance covers less than half the cost.
□ Insurance covers none of the cost.
□ Facebook
□ Twitter
□ Other (please explain)
Please provide any other information about your child that you would like us to
consider.
Authorizations / Signatures
By signing this form, the applicant represents that the information provided is truthful
and accurate. The applicant also recognizes IASF reserves the right to request
verification of any information on the application.
Furthermore, the applicant
acknowledges they have read and understand the IASF Voucher Program Guidelines,
and agrees to comply with all requirements of this program. The applicant holds no
liability to IASF or its members for this program or for the quality of provider services
received. The applicant understands that they accept all responsibility for any taxes due
as a result of this voucher.
Applicant Signature
Date of Application