Atrium Health Teammate Financial Application

Rowan Helping Ministries

226 N. Long St, Salisbury, NC 28144 | 704-637-6838 ext.226 | crisisteam@rowanhelpingministries.org | www.rowanhelpingministries.org
Financial Assistance Application

Financial Services Rowan Helping Ministries can assist with:

-Utility disconnections (electric, water, and natural gas)

-Eviction notices

-First month’s rent

-Heating fuel

-Medication

-Dental Extractions
Are you an Atrium Health Employee? *
Rowan Helping Ministries Crisis Assistance Network provides support for basic needs support through an agreement with your employer, Atrium Health. If you agree, Rowan Helping Ministries may share your employee identification number (Teammate ID) with Atrium Health in order to better understand employee needs. Details on the services you received will not be shared.

Your agreement to allow the sharing of this information is voluntary and not required for you to access the services of Rowan Helping Ministries. If you are willing to share this information, please enter your teammate ID below. By entering your Teammate ID below, you are giving Rowan Helping Ministries Crisis Assistance Network permission to share this information with Atrium Health.
Teammate ID Number:
What to expect.

After your application has been received, a staff member or volunteer will contact you via phone and interview you. During this pandemic, our agency will not be conducting face to face interviews.

· 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

· Copy of social security card.

· Proof of all household income.

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

· Utility disconnect notice 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.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Alternate number you can be reached at

Area Code Phone Number
Email
example@example.com
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.) *

Yes No
What type of financial assistance do you need?
First Month's Rent (Rowan Helping Ministries does not assist with deposits) *

Yes No
First Month's Rent Assistance
Eviction Notice (a copy of the eviction notice will be required- you can attach the notice at the end of this form) *

Yes No
Eviction Assistance
Utility Disconnect Notice (a copy of your disconnect notice will be required and can be attached at the end of this form) *

Yes No
Utility Assistance (*you must contact the utility company and set up a payment plan prior to applying for assistance*)
Other assistance needed:
What caused your financial crisis?
Unexpected expenses (ex: car repairs, home repairs, out of pocket medical expenses, etc.- receipts will be required) *

Yes No
Employer decreased my hours and as a result my monthly income has decreased (pay stubs will be required to show decrease) *

Yes No
Loss of employment (Proof of termination and job searches may be required) *

Yes No
Something else has caused my crisis:
Attach a copy of your Eviction Notice or Utility Disconnect Notice here.

Browse Files

Cancel of
Attach proof of crisis here (pay stubs, termination notice, receipts, etc.)

Browse Files

Cancel of
Do you need help with food and would you like to sign up to receive food assistance?

Yes No
Do you need help with clothing and would you like to schedule an appointment to get clothing?

Yes No
Consent/Release of Information
Signature *

Clear
After submitting your application, you will be redirected to Calendly where you will be asked to select a time and date to be interviewed over the phone. Please only selcect one appointment slot.
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Rowan Helping Ministries

What type of financial assistance do you need?

What caused your financial crisis?

Consent/Release of Information