CarePortal Financial Request Pre-Approval Your work supports families & children in our community CarePortal Financial Request Pre-Approval Name * Name First First Last Last Email * Organization * County * AdamsAllenBartholomewBentonBlackfordBooneBrownCarrollCassClarkClayClintonCrawfordDaviessDearbornDecaturDeKalbDelawareDuboisElkhartFayetteFloydFountainFranklinFultonGibsonGrantGreeneHamiltonHancockHarrisonHendricksHenryHowardHuntingtonJacksonJasperJayJeffersonJenningsJohnsonKnoxKosciuskoLaGrangeLakeLaPorteLawrenceMadisonMarionMarshallMartinMiamiMonroeMontgomeryMorganNewtonNobleOhioOrangeOwenParkePerryPikePorterPoseyPulaskiPutnamRandolphRipleyRushSt.JosephScottShelbySpencerStarkeSteubenSullivanSwitzerlandTippecanoeTiptonUnionVanderburghVermillionVigoWabashWarrenWarrickWashingtonWayneWellsWhiteWhitley Purpose of the request: What is the request for? * Justification: Why is it needed? * Amount needed: How much funding is required? * Total bill: What is the total cost? * Copy of the bill: Attach a copy of the bill. * Drop a file here or click to upload Choose File Maximum file size: 104.86MB File types accepted: doc, docx, jpg, jpeg, jpe, png, and pdf Urgency: How quickly does the bill need to be paid? * Sustained payments: How does the family plan to manage payments moving forward? * Terms * I have already looked for and utilized other community resources to address this need. Submit Request If you are human, leave this field blank.
