Sparrow's Nest Application for Assistance

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 normal household bills. Financial aid may include assistance with power or water bills and the cost of medications for those living in Glynn and McIntosh Counties. We are unable to help with rent, mortgage payments or hotel expenses. We can only assist one time every 12 months.
Examples of qualifying emergencies include:

•Recent Serious Illness •Hospitalization or Surgery •Death in the immediate family that caused you financial hardship •Major car repair •Fire or Accident •Water Leak or Major Home Repair
How do I qualify?

If you have had a recent emergency expense that has caused you to be unable to pay your utility bill or purchase your medications, you may qualify. You need to have normal monthly household income to qualify for assistance. You must have been employed 3 of the last 6 months or have been receiving disability or social security benefits during this time. You must also be able to document the emergency expense with paperwork. This documentation may be hospital discharge papers, repair receipt, doctor note showing work absences, etc. Upon receipt of your application, we will be in contact with you within 5 business days. 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 (layoff, store closure, etc).
Contact Information
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Date of Birth*

MonthDayYear
Date
Do you have children 18 or under living with you?*

YesNo
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)*

YesNo
Which County do you live in? (we can only assist those living in these counties)*

GlynnMcIntosh
Recent Emergency Details
PLEASE NOTE: Job Loss or a reduction in work hours does not meet our qualifications unless related to serious illness or other documented emergency circumstance (layoff, store closure, etc).
Please check what applies to your current emergency.*

Hospitalization or SurgeryRecent Serious IllnessDeath in Immediate Family Causing you Financial HardshipFire or AccidentWater LeakMajor Car RepairMajor Home RepairOther
Please explain why you are in need of assistance and how this recent emergency has impacted your monthly cash flow and ability to pay your bill.*
Please upload your documentation of the recent emergency you have described above. This could include: hospital discharge papers, doctor excuse for work, repair receipts, burial expense receipts, etc. (We will not accept any applications without documents to support your recent emergency. )*

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What type of bill do you need help with?
What type of assistance do you need? (Select only 1)*

Power BillWater BillGas BillMedication Cost
ONLY complete information for the bill you are applying for
Water/Sewer Provider Company Name
Water / Sewer account number
What is the amount due?
Are you on a payment plan?

YesNo
Is your water or disconnected?

yesNo
Upload a copy of your water/sewer bill.

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Electricity Or Gas Company Name
Electricity or Gas Account Number
Is this a prepay account?

YesNo
What is the amount due?
Is your power or gas turned off?

yesNo
Please upload a copy of your electricity or gas bill.

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Name of Pharmacy? (only complete if requesting help with medications)
Pharmacy phone number?
Who is the prescription for?
What is the cost of the prescription?
Please upload a copy of your prescription.

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Employment & Income Information

We require normal monthly household income to qualify for assistance. You must have been employed 3 of the last 6 months or have been receiving disability or social security benefits during this time to apply and be able to provide proof of income, pay stubs, or a separation notice.
Are you currently employed?*

YesNo
Current Employer
How long have you been employed there?
Total monthly income from Job?
If currently unemployed, what was your last day of employment?
If currently unemployed, where was the last place you worked?
How long did you work there?
If unemployed, explain the reason for your job loss. Job loss or reduction in hours does not meet our qualification unless related to serious illness or other emergency circumstance.
Upload a Copy of your 3 most recent Pay Stubs, Proof of Income (social security, disability) OR separation notice if unemployed:*

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How much do you make a month from benefits?
Social Security Benefits:
Disability Benefits:
Child Support:
Alimony:
Food Stamps:
WIC:
Other Assistance:
What are your current monthly expenses?
Rent/Mortgage*
Electricity*
Water*
Car*
Childcare*
Other
Do we have permission to contact your utility provider / pharmacy on your behalf?*

YesNo
We will contact you within 5 business days after receiving your application. Incomplete applications WILL NOT BE REVIEWED
Type your name below to certify all information is true and correct*
Should be Empty:

Sparrow's Nest Application for Assistance

Examples of qualifying emergencies include:

How do I qualify?

Other organizations that may be able to help you include:

Job Loss or a reduction in work hours does not meet our qualifications for assistance unless related to serious illness or other emergency circumstance (layoff, store closure, etc).

Contact Information

Recent Emergency Details

What type of bill do you need help with?

ONLY complete information for the bill you are applying for

Employment & Income Information

How much do you make a month from benefits?

What are your current monthly expenses?

We will contact you within 5 business days after receiving your application. Incomplete applications WILL NOT BE REVIEWED