Twirl to the World - Twirl Assistance Program (TAP) Application

Twirl Assistance Program (TAP) Application

Review eligibility and deadline information below, complete sections 1-4, then submit application along with your electronic signature.
Eligibility: The current grant is intended for self-identified Lesbian, Gay, Bisexual, Transgender, or Queer (LGBTQ) residents 18 years and older in the Charlotte metropolitan area* impacted by the COVID-19 pandemic, who need financial assistance with groceries, medical, and/or transportation costs. Eligible individuals may apply once during this grant period, and all submissions will be considered based on eligibility, need, an objective selection process, and availability of funds.

* The official Charlotte metropolitan area includes the Charlotte–Concord–Gastonia Metropolitan Statistical Area (MSA), which includes Cabarrus, Gaston, Iredell, Lincoln, Mecklenburg, Rowan, and Union counties in North Carolina; Chester, Lancaster and York counties in South Carolina.

Applicants should also work directly with State Employment offices for Unemployment; Utility or telecommunication companies for assistance/payment deferrals for each of those specific services; Financial institutions for mortgages, credit cards, loans, etc.; Landlords for rentals.

Deadlines: Additional 2020 Application Deadline Dates are as follows related to the COVID-19 pandemic:
- July 15th
- July 31st
- Original Dates - April 30th, May 15th & 31st, June 15th & 30th (complete)
Section 1: Personal Information
Name *

First Name Last Name
Mailing Address *

Street Address

Street Address Line 2

City State

Zip Code
Preferred Phone Number *

Area Code Phone Number
Email: *
example@example.com
Birth Date *

Month Day Year
Current Age *
How do you self-identity (LGBTQ)? *

Lesbian Gay Bisexual Transgender Queer
Marital Status *
Select one
Dependants *
Type number, not including yourself
Section 2: Employment and Insurance Status:
Are you currently employed? *

Yes, I am employed full time Yes, I am employed part time No, I have been unemployed or furloughed
Employer Name(s): *
Current or previous employer. If unemployed, type N/A
Have you been terminated or furloughed due to COVID-19 pandemic? *

Yes No
Upload any supporting documentation of furlough or termination

Browse Files
Black out any Social Security or sensitive information. Cancel of
Are you currently receiving or in the process to receive unemployment benefits? *

Yes No
If so, upload any supporting documentation of unemployment claim made.

Browse Files
Black out any Social Security or sensitive information. Cancel of
If not, please describe why not or your plans to do so.
Do you currently have any other means of income or assistance? *

Yes No
If so, please provide income or assistance details.
Do you currently have health insurance? *

Yes No
If so, please provide insurance details.
No account numbers, just type and provider and expected length of coverage
Section 3: Type of Hardship/Emergency Assistance
Reminder: The current grant is intended for self-identified LGBTQ residents 18 years and older in the Charlotte metropolitan area impacted by the COVID-19 pandemic, who need financial assistance with groceries, medical, and/or transportation costs. Preference will be for pre-paid/gift cards or direct payment to service provider(s).

Applicants should work directly with State Employment offices for Unemployment; Utility or telecommunication companies for assistance/payment deferrals for each of those specific services; Financial institutions for mortgages, credit cards, loans, etc.; Landlords for rentals.

(Check all that apply, and then indicate time frame and describe or provide details)
What do you need assistance with?

Groceries Medical (prescriptions, co-pays, etc.) Transportation (to from medical appointments, gas, public)
Need for Groceries Time Frame

Short term (1-2 months) Longer term (3+ months)
Describe or provide details of need for Grocery Assistance.
Need for Medical Assistance Time Frame

Short term (1-2 months) Longer term (3+ months)
Describe or provide details of need for Medical Assistance.
Need for Transportation Assistance Time Frame

Short term (1-2 months) Longer term (3+ months)
Describe or provide details of need for Transportation Assistance.
Acknowledgement, Agreement, and Reminder of Confidentiality
I certify that all of the information in this Twirl Assistance Application (TAP) is true, complete and accurate and the hardship(s) identified above has/have contributed to submission of this request for hardship relief.

I understand and acknowledge that Twirl to the World hosts/members may investigate the accuracy of my statements, may require me to provide additional supporting documentation, and that knowingly submitting false information may disqualify this application.

I understand that any information or documentation I provide will be kept strictly confidential, and that only by my express permission, will Twirl to the World be allowed to share any information with partner agencies/organizations for my benefit.
Applicant Signature: *

Clear
Today's Date *
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

Twirl Assistance Program (TAP) Application

Section 1: Personal Information

Section 2: Employment and Insurance Status:

Section 3: Type of Hardship/Emergency Assistance

Acknowledgement, Agreement, and Reminder of Confidentiality