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Sparrow's Nest Application for Assistance
Please read below before completing application.
Although we would like to help all who are in need, we can only offer financial aid to clients who have recently experienced an emergency that has caused them to be unable to pay their bills. Financial aid may include assistance with power or water bills and the cost of medications for those living in Glynn and McIntosh Counties. You will need to have normal monthly income to qualify. We cannot help pay rent or mortgage payments. If we have helped you within the past 12 months we cannot help you at this time.
We can only assist one time every 12 months.
Examples of qualifying emergencies include:
•Illness •Hospitalization •Death in the immediate family that caused you financial hardship •Major car repair •Fire •Major Home Repair or Water Leak
How do I qualify?
If you have had an emergency expense that has caused you to be unable to pay your utility bill or purchase your medications and can document the emergency with paperwork please complete this application. This documentation may be a doctor bill, repair receipt, hospitalization discharge papers, etc. A staff member will be in contact with you within 3 business days of submitting your application. If you have questions please contact Sabra Slade at sabra@faithworksministry.org
Other organizations that may be able to help you include:
• Coastal Community Action Authority - (912) 264-3281 • Salvation Army - (912) 265-9381 • St. Vincent de Paul (912) 262-6027
Job Loss or a reduction in work hours does not meet our qualifications for assistance unless related to serious illness or other emergency circumstance.
Basic Information
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Do you have children 18 or under living with you?
*
Yes
No
If you have children living at home, please list first names and birthdates.
Have you received financial assistance from the Sparrow's Nest in the past 12 months? (If Yes, we cannot help you again at this time)
*
Yes
No
Which County do you live in? (we cannot assist those living outside these counties)
*
Glynn
McIntosh
Upload a copy of your photo ID
*
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Utility or Prescription Assistance Details
What type of assistance do you need? (Select only 1)
*
Power Bill
Water Bill
Medication Cost
Do we have permission to contact your utility provider / pharmacy on your behalf?
*
Yes
No
Which circumstance is your assistance need related to?
*
Hospitalization
Recent Serious Illness
Death in Immediate Family Causing you Financial Hardship
Fire
Water Leak / Other Major Home Repair
Major Car Repair
Other (Explain below)
Please explain your circumstances, why you are in need of assistance and how it has impacted your cash flow and ability to pay your bill.
*
Please upload your documentation of the recent emergency you have described above. (Written documentation is required to qualify for assistance.)
*
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Account Details
Please fill in the information below.
(you only need to fill in the information that applies to the type of assistance you are applying for)
JWSC Water / Sewer account number
What is the amount due?
Are you on a payment plan?
Yes
No
Is your water disconnected?
yes
No
Upload a copy of your water/sewer bill.
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Electricity Provider's Name
Your Electricity Provider Account Number
Is this a prepay account?
Yes
No
What is the amount due?
Is your power turned off?
yes
No
Please upload a copy of you electricity bill.
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Name of Pharmacy?
Pharmacy phone number?
Who is the prescription for?
What is the cost of the prescription?
Employment & Income Information
You need to have normal monthly household income to qualify for assistance.
Current Employer
*
Total monthly income from Job?
How long have you been employer there?
Upload a Copy of your 3 most recent Pay Stubs or other Proof of Income:
*
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List all monthly benefits and assistance received
Social Security Benefits:
Disability Benefits:
Child Support:
Alimony:
Food Stamps:
WIC:
Other Assistance:
I certify that all of the above information I have provided is true and correct:
Signature
*
Submit
Should be Empty: