Please read instructions below then fill out online form once you have given your LA4K Grant Package to your provider to email us.

1. Grant Package consists of the “Applicant Certification Form” and the “Health Care Provider Form.”
2. Applicant Fills out “Applicant Certification Form.”
3. Applicant gives provider the entire Grant Package, which includes both forms and 1st pg of IRS 1040.
4. The provider is responsible for completing the “Health Care Provider Form” and emailing the entire Grant Package to COTBDAA.
5. Applicant fills out this online Follow-up form to notify us when provider received the Grant Package so we can follow up and inform the applicant on status.