APPLICANT INFORMATION

Full Legal Name:

Date of Birth (MM/DD/YYYY):

Phone Number:

Email Address:

Preferred Contact Method:

PhoneEmailText

PERSONAL DEBT CATEGORY (SELECT ALL THAT APPLY)

Choose the types of debt or financial pressure you are struggling with.

Credit Card DebtMortgage / Housing PaymentsAuto Loan DebtStudent Loan DebtMedical BillsPersonal LoansPayday / Advance LoansIRS / Tax DebtUtility Bills / Disconnect NoticesRent Past Due / Eviction RiskBusiness-Related DebtChild Support ArrearsCourt Fines / Legal FeesInsurance BillsBankruptcy ConsiderationOther:

If Other, please specify:

REASON FOR REQUEST

Please select all reasons for seeking assistance:

Job loss or major income reductionMedical emergency or health-related financial impactOverwhelming personal debtEmergency or unexpected expenseSmall business financial hardshipDisaster-related lossRisk of eviction or housing instabilityOther:

If Other, please specify:

Briefly describe your situation:

FINANCIAL SNAPSHOT (INDIVIDUAL/HOUSEHOLD)

(Skip if applying ONLY as a business.)

Current Monthly Income (before taxes):

Under $1,000$1,000–$2,500$2,500–$4,000$4,000–$6,500$6,500+

Household Size:

12345+

Current Employment Status:

—Please choose an option—Employed full-timeEmployed part-timeSelf-employedUnemployedRetiredOther

If Other Employment Status, please specify:

BUSINESS INFORMATION (IF APPLICABLE)

(Skip if not applying as a business.)

Legal Business Name:

DBA (if applicable):

Business Structure:

—Please choose an option—Sole ProprietorLLCCorporationNonprofitOther

If Other Business Structure, please specify:

Years in Operation:

Less than 11–33–55+

Number of Employees:

12–56–1011–2526+

Describe the financial hardship your business is facing:

SUPPORT REQUESTED

Type of Support Needed:

Emergency financial reliefSmall business reliefDebt-related assistanceEducational programsFinancial literacy coursesOther:

If Other Support, please specify:

Requested Amount (if known):

How will this support help you stabilize or move forward?

OPTIONAL DOCUMENT UPLOADS

Attach any supporting documents (optional).

Proof of income:


Bills / Notices:


Financial statements:


Lease / Eviction documents:


Medical bills:


Proof of emergency or disaster:

Other supporting documents:
Other:

APPLICANT AGREEMENTS

Please check to agree:

I certify all information provided is accurate.I understand submitting this form does NOT guarantee approval.I understand assistance is based on need, resources, and eligibility.I authorize the Foundation to contact me for additional information.I agree to the Privacy Policy and Terms of Use.I understand the Foundation does not provide legal, tax, or investment advice.

SIGNATURE

Applicant Signature (type full name):

Date:

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