Eagle Valley Family Assistance Fund

Eagle Valley Family Assistance Fund

Application Form | Page 1 of 13
Who referred you to the Eagle Valley Family Assistance Fund?
Application Type?*

Just myself (single or married)Jointly with my spouse

Children

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Number of Children Living with You?*

Section: Child not living with you
Number of children not living with you and/or your spouse?*
List children not living with you. Explain any custody issues.

Current Employment

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Your Current Employer*
Position / Title*
How Long?*
ex: 3 years 5 months
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Immediate Supervisor*

Previous Employment

Page 4 of 13
Your Previous Employer
Position / Title
How Long?
ex: 3 years 5 months
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Immediate Supervisor

Medical History

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Your Medical History / Problems / Medications
Please indicate both past and current.
Spouse's Medical History / Problems / Medications
Please indicate both past and current.
Children's Medical History / Problems / Medications
Please indicate both past and current.
Additional medical information, including outstanding medical bills.

Education

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Your Education*
Spouse's Education*

Additional History

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Substance Abuse
Spousal Abuse
Arrests / Criminal Convictions

Financial Information: Assets

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Cash In Bank / On Hand*
Do you own any property?*

YesNo

Do you own any vehicles?*

YesNo

Other Assets?
Describe each asset and value.

Financial Information: Liabilities

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Do you have any credit cards?*

yesno

Other Liabilities or Outstanding Debts*
Please describe and list value and whether owed by Husband (H), Wife (W) or Joint (J)

Financial Information: Income

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Monthly Income*

	Amount
Gross Pay
Child Support
Interest/Dividends
Social Security
Welfare
Other

Total Monthly Income
Income Notes / Explanation

Financial Information: Expenses

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Monthly Expenses*

	Amount
Rent / Mortgage
Car Payment
Car Payment
Total Credit Card Payments
Other Loan Payments
Day Care
Cable / Phone / Internet
Insurance (Car / Health / Home / Rental)
Child Support / Alimony
Gas
Electricity
Water
Cell Phone
Food / Household Items
Gas
Personal Expenses
Other

Total Monthly Expenses
Expense Notes / Explanation

Financial Request

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Amount Requested?*
Money to be used for?*
If any of the above information is found to be false, this will constitute grounds for denial of this loan. The above statements are true to the best of my knowledge.
Your Signature*

Clear
Your Printed Name*
Spouse's Signature*

Clear
Spouse's Printed Name*

Waiver of Legal Rights

Page 13 of 13
Release of Confidential Information

Applicant Signature(s) at the bottom of this document constitute permission for the Eagle Valley Family Assistance Fund ("Fund") or any of its member to gather information deemed appropriate by the Fund. This information includes, but is not limited to, financial, medical, employment, housing, public assistance, or any other information needed by the Fund for maintenance of its non-profit purposes.

The Applicant(s) allow the Fund to contact any individuals or entities to verify the validity of any representations made by the applicant(s).

The signature(s) serve to release the Fund from any subsequent liability for gathering the information heretofore confidential.
Your Signature*

Clear
Your Printed Name*
Spouse's Signature*

Clear
Spouse's Printed Name*
Should be Empty: