Letter of Request for Patient Education Grant Application (Required document - click link for printable Patient Education Grant application instructions, including the Letter of Request)
Prepare a SIGNED Letter of Request on ORGANIZATIONAL LETTERHEAD. You will be uploading an electronic version of this document as part of your online grant application. Your letter of request will not be considered unless it includes all of the following information:

• Title and date of the event, and the amount of funding being requested.
• Organization's 9-digit tax ID number.
• Statement verifying that decisions involving the selection of faculty will not include Tibotec Therapeutics.
• Statement verifying that any representations of Tibotec Therapeutics products during the educational activity will be within FDA-approved labeling.
• Assurance that there has been no condition of purchase, use, or recommendation of Tibotec Therapeutics products associated with this request for funding.
• A statement as to whether Tibotec Therapeutics will receive the right to use the materials produced for the educational programs for patients.
• Name and address to which the check should be made payable and mailed if your request is approved.

Patient Education Grant Application Supplement (Required form)
Please complete a Patient Education Grant Application Supplement form and upload with your online grant application. This supplement includes the following information:

• Purpose of the educational activity
• Approximate number of attendees/participants expected
• A comprehensive Needs Assessment is required for all educational grant requests. A Needs Assessment is the evaluation of a need or perceived need of the specific learners to be targeted by the educational activity (see the Grant Application Supplement for further details).
• Detailed explanation of the learning objectives of the educational activity. Learning objectives must tie to the stated need in the Needs Assessment.
• Detailed agenda / course outline

Budget (this budget template is required for requests for funding of programs totalling under $100,000. For programs totaling over $100,000, you may use this template or your own.)
Budget should be for the entire program (not just the portion for which you are requesting funding).

• The budget for Patient Education programs must include the following breakdowns (where applicable):
• Meals - provide breakdown of cost per meal, per attendee/faculty/speaker.
• Faculty travel costs - provide breakdown of airfare, transportation and lodging per speaker, per day/night
• Honoraria - provide breakdown per speaker
• Staffing - provide breakdown of position, % FTE and responsibility

W-9 Form (Required document)
A signed and dated IRS form W-9 must be uploaded with each grant application (even if submitted with previous grant applications). The information contained in the W-9 form must match that of the organization that would receive funds if the grant were approved.