Alaska State Auxiliary
Auxiliary Special Assistance Request Form
Name _________________________________________________________________
Address _______________________________________________________________
City ________________________ State __________________________
Auxiliary location & # ________________________________________
Special Assistance needed: (wheelchair: electric or not, breathing apparatus, interpreter, nursing assistance etc.) Please give exact details.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Location where needed __________________________________________________
Dates ________________________________________________________________
Amount _________________
Reviewed by ________________________________________________
________________________________________________
________________________________________________
Date Reviewed ______________________________________________
Accepted ______________________ Denied _______________________
Amount Approved ____________________________________________