Follow the steps to complete your application effectively.

1. Click ‘Get Form’ button to retrieve the application form and open it in your preferred editor.
2. Begin with the applicant contact information section, providing your name, telephone number, street address, mailing address (if different), email address, city, state, and ZIP code.
3. Next, if applicable, indicate if you wish to appoint a representative. Fill in the representative's name and email address as necessary.
4. In the demographic and financial information section, provide your gender, date of birth, race/ethnicity, income source and amount, and total liquid resources.
5. Complete the health insurance information section, listing the name of the policyholder, name of the insurance provider, who is covered, and the policy number.
6. Answer how you found out about the program in the source of referral section.
7. Confirm your eligibility by indicating if you are a Delaware resident and providing details about your brain injury diagnosis, including the date of the injury.
8. Select the desired services you are applying for by checking all applicable boxes and providing an estimated cost if known.
9. Respond to questions regarding the availability of services through the Delaware Department of Health & Social Services, detailing your current status with any related programs.
10. In the acknowledgment & signature section, review the statements and sign the application electronically, affirming the accuracy of the information.
11. After completing all required fields and attaching any necessary documentation, click the ‘SUBMIT’ button to send your application back to the State Council for Persons with Disabilities.

Take the first step towards assistance by completing your DE Application For Brain Injury Fund Assistance online today.