CCMW EMERGENCY BURSARY APPLICATION FORM

CCMW EMERGENCY BURSARY APPLICATION FORM
If you are going through unexpected financial difficulties because of violence that you have faced or legal fees, CCMW is here to help you. Our Emergency Bursary program provides urgent financial help for CCMW clients in these situations.

You can request emergency funding by filling out this application form. We consider each request based on the financial need of the client, the merits of the situation, and how severe the situation is.

The CCMW Emergency Bursary funding is only for

a) current CCMW clients who have contacted us for legal services coordination and/or support coordination for gender-based violence and abuse and

b) who are in an unexpected financial crisis. You must be an active CCMW client at the time the financial crisis happens. It must also have a direct impact on your wellbeing and/or safety.

Please review the CCMW Emergency Bursary Policy and Procedures before filling out this form. If your Application is missing supporting documents, it will not be considered.

To Apply
- Complete all sections of the CCMW Emergency Bursary
  Application Form. Incomplete applications will not be reviewed.
- Include a personal statement in your application that shows how you calculated the amount of money you need.
- Attach all relevant supporting documentation such as receipts for rent,
  proof of loss of employment (e.g., letter/email from employer or Record of
  Employment) and two recent pay stubs.
Please note: Your application may be audited. Please keep all supporting documentation such as receipts, bank statements, cancelled cheques, etc. Giving false or misleading information could result in your application being denied.
Full Name*
Date of birth*

MonthDayYear
Phone*
Email*
example@example.com
What is your relationship status? *
How many dependent (under 18) children do you have?*
City*
Province*
Is it safe to contact you by phone?*

YesNo
Is it safe to contact you by phone?*

YesNo
Have you submitted a CCMW client intake form?"

YesNo
What date did you submit a CCMW client intake form?*

MonthDayYear
Date
Monthly Income

Please include all sources of income and all expenses. Please provide any other information that you fee may help in determining your financial need.
Employment/self-employment
Savings/Investments/RESP
Student loan
Employment insurance
Social Assistance
Pension(s)
Child tax credits
Child support
Spouse income/spousal support
Tax rebates (average)
Bursaries/scholarship
Support from parents
Other (specify)
Monthly Expenses

Please include all sources of income and all expenses. Please provide any other information that you fee may help in determining your financial need.
Rent/mortgage
Groceries
Medications (uninsured)
Electricity, heat, and water
Internet access
Telephone/cell phone
Childcare
Child school expenses (average)
Child bus passes
Child support payments
Clothing (yourself and/or family)
Bus pass (your own)
Car/home insurance (average)
Car payment
Gas and parking
Loan/credit card payment
Other (specify)
Please provide information about your current financial situation, such as family income, expenses, outstanding debts, and any financial barriers you may be facing. By doing so, it helps the Committee understand your genuine need for financial support. Maximum 500 words*

0/500
File Upload*

Attach all relevant supporting documentation such as receipts for rent, proof of loss of employment (e.g., letter/email from employer or Record of Employment) and two recent pay stubs.
Cancelof
AUTHORIZATION AND DECLARATION
I hereby declare that the information contained herein, all statements made and all supporting documents submitted in connection with this application are true, correct and complete. I understand that any misrepresentation or incomplete disclosure on or relating to this application may result in the cancellation of a bursary amount. I understand that successful submission of my application does not guarantee that I will receive a bursary amount.
Signature of Applicant*
Date*

MonthDayYear
Date
Should be Empty:

CCMW EMERGENCY BURSARY APPLICATION FORM

Monthly Income

Monthly Expenses

AUTHORIZATION AND DECLARATION