Financial Application

Curtis P. Crowner Foundation

P.O. Box 29171 Baltimore, MD 21205 | 410-352-7794 | thecpcfoundation@gmail.com
Financial Assistance Application

The CPC Foundation can assist with:

Rent (up to $1000), Utility Bills (up to $250), Medical Premiums, Home Cleaning Service, Transportation, Hospital Bedding, Caterer (for home cook meals)
What to expect.

After your application has been received, a staff member will review and process your application. The application process will take 72 hrs and you will receive a response within that timeframe if all documents are received.

· Our agency cannot guarantee you will be offered assistance.

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

Documents required.

· Picture ID (driver’s license, passport, etc.)

· A statement from physician of days out of work due to illness

· Leasing agreement or letter from landlord with contact number

· Mortgage Statment

· Utility notice if requesting utility assistance. The account must be in the name of someone residing in the home.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
What type of financial assistance do you need?
Rent (a copy of leasing agreement)*

YesNo
For help with Rent, please list the landlord and their contact number.
Utility Bill (a copy of your utility bill will be required and can be attached at the end of this form)*

YesNo
Medical Premiums (medical bill will be required and can be attached at the end of this form)*

YesNo
Other expenses (transportation, caterer, home cleaning service, and hospital bedding) provide vendors information below.*

YesNo
Please specify below:
Attach a copy of your Lease/Letter from Landlord or Utility Bill here.

Browse Files

Cancelof
Attach all other documents

Browse Files

Cancelof
By signing and submitting this application for financial assistance, you give your consent for The CPC Foundation to make necessary inquiries to confirm financial obligations and information from other sources. The information you provide will be collected and stored in The CPC Foundation database and only used for the services you are requesting assistance with.

You also certify all information provided to The CPC Foundation is freely voluntarily and without coercion given. All individuals must provide accurate, correct and complete information to The CPC Foundation to determine eligibility. Failure to do so may result in a denial of services.
Signature*

Clear
Should be Empty:

Curtis P. Crowner Foundation

What type of financial assistance do you need?