Financial Application

Financial Assistance Application

Financial Services Rowan Helping Ministries can assist with:

Assistance Needed:*

What to expect.

Our agency is currently conducting phone interviews. After your application has been received, a staff member or volunteer will contact you via phone for your interview. If any of your contact information changes before your scheduled appointment please let us know via email crisisteam@rowanhelpingministries.org.

· Please be prepared to explain what created your crisis and to discuss all household income and expenses.

· Our agency may require that you or others in your home search for work or apply for other benefits to improve your situation before we offer assistance.

· We may also require you to access services at another agency before being interviewed, if we believe they can better meet your needs.

· Our agency cannot guarantee that if you are interviewed, you will be offered assistance.

· If you are approved for financial assistance, all checks are mailed directly to the vendor.

Documents that may be requested.

· Picture ID (driver’s license, passport, etc.) for each household member over the age of 18 years old

· Verification of last 4 of your Social Security Number.

· Proof of all household income for all members of the household over the age of 18.

· Expense receipts for the circumstance you identify as creating your crisis. (Ex: car repair, home repair, etc.)

· Utility disconnect notice and a copy of the bill if requesting utility assistance. The account must be in the name of someone residing in the home.

· Court eviction notice if requesting rental assistance. Rowan Helping Ministries only pays rent to the actual property owner and this information is verified on the Rowan County GIS.

Please note that we are receiving a large number of requests for assistance daily. Please make sure to fill out application completely and include all information requested.

Appointment*

Are you a resident of Rowan County? (Our agency can only assist residents of Rowan County. Please contact 211 for a list of agencies that can help in your area.)*

YesNo

Name*

First NameLast Name

Date of Birth*

Date

Primary Client Last four of Social Security Number*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone Number*

Alternate number you can be reached at

Email

example@example.com

Source of Income-Please check all that apply.

Total Household Income *

All income for all members of the home in the last 30 days.

Household Members*

Number of individuals who live in the home.

Household Members*

Total Monthly Income Sources*

Monthly Household Expenses*

Have you filed your 2023 income tax return?*

YesNo

If you answered yes above what is your refund amount? $ blanks
When did you receive or expect to receive your refund? blank

Does your family receive Supplemental Nutrition Assistance Program (SNAP/EBT, formerly Food Stamps) benefits?

YESNOApplied for BenefitsOther

Do you need a Spanish interpreter?

YESNO

Type a question

Type option 1Type option 2Type option 3Type option 4

Ethnicity: Please select all that apply.*

Are you a Veteran?*

YesNo

Rowan Helping Ministries

What type of financial assistance do you need?

What caused your financial crisis?

Consent/Release of Information