WYOMING DISABLED HUNTERS FINANCIAL ASSISTANCE …

[Pages:1]WYOMING DISABLED HUNTERS FINANCIAL ASSISTANCE APPLICATION

Application must accompany your WDH Hunt Application form for all antelope, deer and elk hunters!

Print all responses except where signatures are required!

APPLICATION INFORMATION

Name:

Date of Birth:

Email:

Cell Phone:

Address:

City:

State:

Zip:

ANNUAL INCOME

Annual Income: $

per Year

Number in Houseshold:

Please attach first page of most recent tax return as proof of annual income (WDH prefers 1040 form or equivalent, or

SS Benefit form). If you do not file taxes, please provide other proof of monthly income.

Have you attached Annual Income documentation? Yes or No (Circle One)

REFERENCES

Name:

Cell #:

Relationship to Applicant:

1.

2.

AMOUNT OF TRAVEL ASSSISTANCE REQUESTED

Hunting License:1 $________ =Antelope $________=Deer $_________=Elk

Cost = $

Mileage:2

__________M__iles (1-Way) X 2 X $0.25/mile (WDH pays rd-trip)

Cost = $

Lodging Costs:3 _________ # Nights X $_________per Night

Cost = $

Airfare Costs:

__________# Travelers X Ticket Cost of $_________ per person

Cost = $

Total = $

Information on Airline Travelers: (Include full names as they appear on driver's license)

Hunter:

Date of Birth:

Caregiver:4

Date of Birth:

COMMENTS

1. Approx Cost: Antelope=$326, Deer=$374, Elk=$692 (all non-resident). Check Wyoming Game & Fish website.

2. Mileage is round-trip travel from home location to WDH hunting destination (i.e. suggest Google Maps)

3. WDH pays actual lodging costs up to a maximum of $100/Night while traveling.

4. Your able-bodied, accompanying caregiver MUST be knowledgeable about & tend to 100% of your medical care

needs; this responsibility is upon you & your caregiver and not any WDH volunteer or companion hunter.

5. Receipts for airfare and/or lodging costs must be submitted to WDH for reimbursement to occur.

6. Application received-by deadlines: Elk = Jan 23, 2019 Antelope/Deer = May 1, 2019

7. You submit only one application if interested in hunting one, two or all three species (can only hunt one).

Please return this form to:

Wyoming Disabled Hunters P.O. Box 2232 Cody, WY 82414

For questions, contact:

Corey McGregor, President 307-899-0790 corey.mcgregor@

OR Terry Skinner, Vice-President 307-250-3771 tkskinner25@

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