Supporting Documentation Form for RCAW Grant Programs

Respite Care Association of Wisconsin
www.respitecarewi.org
[email protected]
608-222-2033

RCAW is a statewide nonprofit serving all 72 counties and 11 tribes, and our mission is to promote, support, and expand quality statewide respite care across the lifespan.

Please review the following Overviews, Policies, and Procedures:
Caregiver Respite Grant Program (CRGP): https://respitecarewi.org/wp-content/uploads/2024/03/CRGP-OPP-1.pdf
Supplemental Respite Grant Program (SRGP): https://respitecarewi.org/wp-content/uploads/2025/02/SRGP-OPP-02.2025.pdf

Purpose and intent of the SDF: The Supporting Documentation Form (SDF) is required to be completed by the applicable (depending on the age of the care recipient) Aging and Disability Resource Center (ADRC), Tribal ADRS, or County on behalf of family or primary caregivers who wish to apply for RCAW's Caregiver Respite Grant Program or Supplemental Respite Grant Program.

The SDF verifies that other Long-Term Care (LTC) waivers and caregiver support programs cannot serve the applicant with respite care services, as this program is the payor of last resort. For a list of programs, visit this link: https://respitecarewi.org/grants/caregiver-respite-grant-program-crgp/

If an applicant needs respite care and chooses not to apply for LTC waivers or caregiver support programs or is ineligible for LTC waivers or caregiver support programs, question #17 on the form allows you to explain the situation.

RCAW only accepts SDFs from governmental agencies such as ADRCs, Counties, etc., or entities contracted by them to verify eligibility criteria for applicants. SDFs will only be processed if submitted by those mentioned above.

SDFs will not be processed if family/primary caregivers submit them. If you are a family caregiver and need assistance finding the contact information for the ADRC or County office, please visit Respite Resources Across the Lifespan: https://respitecarewi.org/respite-resources/

RCAW reserves the right to deny grant requests at any step of the process at our discretion. If an applicant has completed an application and is denied, they can appeal denials using the Grant Denial Appeal Form: https://respitecarewi.org/wp-content/uploads/2022/10/LS-Grant-Denial-Appeal-Form.pdf.

For additional help, please get in touch with RCAW at [email protected].

Today's Date *

Which grant is the applicant applying for? Please do not check "both" below unless the applicant intends to apply for both, as doing so will skew RCAW's intake inquiry data.

Caregiver Respite Grant Program (CRGP) funds up to five days of respite care within 30 days of approval.

Supplemental Respite Grant Program (SRGP) funds supplemental respite services. Here is a list of Allowable Expenses https://respitecarewi.org/wp-content/uploads/2024/12/SRGP-Allowable-Expenses-12.24.24.pdf

Which grant is the applicant applying for? *

Caregiver Respite Grant Program (CRGP)

Supplemental Respite Grant Program (SRGP)

Both (do not check "both" below unless the applicant intends to apply for both, as doing so will skew RCAW's intake inquiry data)

Applicant First Name *

Applicant Last Name *

Applicant's Email *

What is the age of the Care Recipient? (person receiving care from the family/primary caregiver) *

Professional Representation *

I am a professional representing a family/primary caregiver from governmental agencies such as ADRCs, Tribal ADRS, County Agency, etc., or entities contracted by them.

SDF Processing *

I understand that SDFs will NOT be processed if submitted by family/primary caregivers and are considered null.

Your Name *

Job Title *

Phone Number *

Email *

Name of Your Agency *

Caregiver Street Address *

City *

State *

ZIP *

County *

If the family caregiver you are completing the Supporting Documentation Form for lives in the following counties, you verify they are not actively receiving support and funding from the ILSP program and have already exhausted NFCSP/AFCSP.

***Please note that the Caregiver Respite & Supplemental Respite Grant Programs (CRGP/SRGP) are intended to support family caregivers receiving respite care services. These grants are not designed to support care recipients receiving one-time or periodic services or continued services.***:

Adams
Green Lake
Brown
Chippewa
Columbia
Dane
Dodge
Dunn
Eau Claire
Green Lake
Kenosha
Milwaukee
Sauk
St. Croix
Walworth
Washington
Waushara

Independent Living Support Pilot (ILSP) *

The family caregiver lives in the above counties, and I verify the family caregiver is not actively receiving support through the ILSP AND has already exhausted NFCSP/AFCSP funds.

Does Not Apply, the family caregiver does not live in the above counties.

What Long-Term Care (LTC) waiver program or caregiver support program did the applicant consider or apply for first? *

Eligibility Criteria: To the best of your knowledge, the applicant has applied for Long-Term Care Waiver support(s) or other programs and:

Note: Applicants receiving NFCSP/AFCSP must exhaust their funds BEFORE applying for this grant. *

If you selected "Has applied and is receiving supports through CLTS, and needs flexibility for supplemental respite services not covered by CLTS," please explain why:

Disclaimer: RCAW is not the employer of service providers. RCAW is not providing any direct or indirect services. Applications will be approved case-by-case based on the application's merits, acuity of the care recipient, geographic location, and available resources, with the intent of preserving grant funds for those most in need. *

I agree

Fraud Discalimer: RCAW funds the majority of its programs with state and federal funds. We are responsible for ensuring funds are used for their intended purpose and in a manner to conduct the goals and objectives identified in the grant.

RCAW reserves the right to deny a grant application if it suspects or detects fraudulent information contained on a grant application RCAW also reserves the right to report suspected fraud to the appropriate officials, and applicants will be banned from applying for grants in the future. They may be subject to repayment of said grant funds to RCAW. All parties involved in grant fraud can potentially be charged with government grant fraud. Using state and federal grant dollars for unjust enrichment, personal gain, or other than their intended use is a form of theft, subject to criminal prosecution.

I have read and understand the Grant Program Detailed Fraud Disclaimer. The link is provided here: https://respitecarewi.org/wp-content/uploads/2023/05/Grant-Program-Detailed-Fraud-Disclaimer.pdf

Fraud Disclaimer Acknowledgement *

Yes, I have read and understand the Grant Program Detailed Fraud Disclaimer.

E-Signature *

Clear