Helping Hands Grant Application

- Emergency Assistance Program
  
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  Date of Application REQUIRED Please fill out this field. Please enter valid data.
  
  Applicant Information
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Social Security Number REQUIRED
  SSN or ID number
  Please fill out this field. Please enter valid data.
  
  Street Address REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  How long have you lived at this address? REQUIRED Please fill out this field. Please enter valid data.
  
  Referred by: REQUIRED Please fill out this field. Please enter valid data.
  
  Additional Information
  
  How many children are in the home (under age 18)? REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to applicant? REQUIRED Please fill out this field. Please enter valid data.
  
  How many adults are in the home (not including applicant)? REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to applicant? REQUIRED Please fill out this field. Please enter valid data.
  
  Marital Status REQUIRED Please fill out this field.
  
  Primary Language
  
  Primary Language REQUIRED Please fill out this field.
  
  If Other, please specify: Please enter valid data.
  
  Residency REQUIRED Please fill out this field.
  
  Do you identify as: REQUIRED Senior Retired Veteran Disabled Not applicable Please fill out this field.
  
  Employment
  
  Employed? REQUIRED Please fill out this field.
  
  If yes:
  
  Current employer: Please enter valid data.
  
  Employed since: Please enter valid data.
  
  Employer address: Please enter valid data.
  
  Supervisor: Please enter valid data.
  
  Previous employment
  
  Name of employer: REQUIRED Please fill out this field. Please enter valid data.
  
  Length of employment: REQUIRED Please fill out this field. Please enter valid data.
  
  Full-time? REQUIRED Please fill out this field.
  
  Income Source (indicate MONTHLY amount)
  
  Income Source:
  
  Alimony Please enter valid data.
  
  Child Support Please enter valid data.
  
  Employment Please enter valid data.
  
  Food Stamps Please enter valid data.
  
  Retirement Please enter valid data.
  
  Social Security Please enter valid data.
  
  SSI/SSD Please enter valid data.
  
  Medicaid REQUIRED Yes No Please fill out this field.
  
  TANF (AFDC) Please enter valid data.
  
  Unemployment Please enter valid data.
  
  Veteran Benefits Please enter valid data.
  
  Other (Specify) Please enter valid data.
  
  Total Monthly Household Income REQUIRED Please fill out this field. Please enter valid data.
  
  Total Expenses (indicate MONTHLY amount)
  
  Monthly Expenses:
  
  Alimony Please enter valid data.
  
  Appliances/Furniture Please enter valid data.
  
  Car Insurance Please enter valid data.
  
  Car Payment Please enter valid data.
  
  Child Care Please enter valid data.
  
  Child Support Please enter valid data.
  
  Electricity Please enter valid data.
  
  Food Please enter valid data.
  
  Gas/Propane Please enter valid data.
  
  Loans Please enter valid data.
  
  Medical Please enter valid data.
  
  Rent/Mortgage Please enter valid data.
  
  Telephone Please enter valid data.
  
  Transportation Please enter valid data.
  
  Other (Specify) Please enter valid data.
  
  Total Monthly Household Expenses REQUIRED Please fill out this field. Please enter valid data.
  
  Please provide brief summary information on reason and/or other extenuating circumstances or supporting comments on why assistance is needed, what assistance is for, how much you can contribute, and amount you are requesting: REQUIRED Please fill out this field.
  
  Submit
  
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