Financial Assistance Request Form
Our vision is to partner with the community to transform lives... we look forward to hearing your story.
*Please note that we are currently only able to assist clients in the cities of Bulverde, Spring Branch, Canyon Lake, Fisher, and Blanco. You can visit our website www.hopecenterministries.com for a list of additional resources.
Please fill out the form below. This form must be completed by the person whose name is on the bill for which you are requesting assistance.
For example: If you need assistance repairing your car, the person on the car loan/title must be the person filling out the form
Status
Please Select
Not Reviewed
Does Not Qualify - For Now
Waiting on Client
Caution - See Notes for Details
Apt Set
Done - Seen for Apt.
Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
*
Street address (1234 Hope Drive)
Address
Apt #, unit #, Lot #, etc.
City
*
Please Select
Bulverde
Spring Branch
Canyon Lake
Fisher
Blanco
Other
State
*
Zip Code
*
We currently are only able to assist clients in Spring Branch, Bulverde, Canyon Lake, Fisher, and Blanco.
We apologize that we are not able to personally assist you at this time but encourage you to check out SACRD.ORG to find a list of resources for any needs you may have based on your area.
Date of Birth
*
-
Month
-
Day
Year
Driver's License Number
Enter ONLY numbers
Driver's License Expiration Date
-
Month
-
Day
Year
Date
Are you employed
*
Yes
No
Name of Employer
Employer Phone Number
Active Duty Military
*
Yes
No
Veteran
*
Yes
No
Do you receive Food Stamps (or TANF)
*
Yes
No
If yes, enter the total monthly amount $
type numbers only - no dollar signs, decimals, or commas
Are you legally married?
*
Yes
No
Spouse's First and Last Name
Spouse's Date of Birth
-
Month
-
Day
Year
Spouse's Employer
Phone Number of Spouse's Employer
Are there persons besides you & your spouse living in your household
*
Yes
No
Please list ALL persons living in your household
Name
First & Last
Age
Male or Female
Male
Female
Relationship to you
School
List the school they attend, if any
Is there anyone else living in your household
Yes
No
Name
First & Last
Age
Male or Female
Male
Female
Relationship to you
School
List the school they attend, if any
Is there anyone else living in your household
Yes
No
Name
First & Last
Age
Male or Female
Male
Female
Relationship to you
School
List the school they attend, if any
Is there anyone else living in your household
Yes
No
Name
First & Last
Age
Male or Female
Male
Female
Relationship to you
School
List the school they attend, if any
Is there anyone else living in your household
Yes
No
Name
First & Last
Age
Male or Female
Male
Female
Relationship to you
School
List the school they attend, if any
Is there anyone else living in your household
Yes
No
Name
First & Last
Age
Male or Female
Male
Female
Relationship to you
School
List the school they attend, if any
List TWO personal references NOT living with you
Reference 1 Name
*
First Name
Last Name
Reference 1 Phone Number
*
Please enter a valid phone number.
Reference 2 Name
*
First Name
Last Name
Reference 2 Phone Number
*
Please enter a valid phone number.
Are you a member of (or do you regularly attend) a church
*
Yes
No
Which church?
Annual Income
*
The amount of money you & your spouse bring in each year
What is the nature of your need at this time?
*
Please Select
Utilities (Water, Electric, Trash, etc)
Food
Rent/Mortgage
Phone &/or Internet Bill
Prescriptions
Home Repairs
Auto: Insurance, Payment, &/or Repairs
Make & Model of Automobile
Year
If unsure, enter your best guess using numbers only
License Plate Number
Please describe, in as much detail as possible, the circumstances that led to your current situation
*
Have you sought assistance through any other channels or resources?
*
Yes
No
Name of Agency
blanks
Assistance Requested
blank
Date
Name of Agency
blanks
Assistance Requested
blank
Date
Name of Agency
blanks
Assistance Requested
blank
Date
Name of Agency
blanks
Assistance Requested
blank
Date
Have you ever received FINANCIAL assistance from The Hope Center in the past? Please note that it is our general policy to offer financial assistance not to exceed $250 annually per household.
*
Yes
No
Reason for past assistance
Monthly Budget
Please use your "bank statement" to fill out the budget below to the best of your ability. This will not only help us to serve you better now, but it will also allow us to better assist you in achieving financial independence and stability. You will need to bring your statement with you when you meet with us. Your statement may be from a traditional bank or any other platform you use to send/receive money (PayPal, Venmo, Cash App, etc). Your budget should reflect each entry for the entire month.
Income Sources
Amount
Salary/Wages
SS/SSI/Disability
VA Disability
Food Stamps
TANF
Retirement
Pension
Odd Jobs
Family Support
Child Support
Other
Fixed Monthly Expenses (expenses that are the same each month)
Amount
Rent/Mortgage
Land/Lot
Car Payment
Car Insurance
Health Insurance
Life Insurance
Child Care
Loans
Credit Cards
Savings Account
Church/Donations/Tithes
Home Insurance
Other
Monthly Expenses
Amount
Electric
Gas (home)
Propane
Water
Fuel (vehicle)
Telephone (landline, cell)
Groceries
Laundry
Diapers/Baby
Pharmacy
Doctors
Storage Unit
Other
Non-Essential Expenses
Amount
Tobacco
Alcohol
Pet Food
Beauty Shop/Barber (hair, nails)
Internet
Cable or Streaming Services
(Netflix, Hulu, Etc)
Bingo
Lottery
Movies
Eating Out
Other
TOTAL INCOME
TOTAL EXPENSES
EXCESS/DEFICIT
We will need a copy of your driver's license for your financial assistance appointment. To save time and help us get you in quicker, you may upload a picture of your license here. Please note, you will still need to bring this with you to your appointment.
Browse Files
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Choose a file
Cancel
of
We will need to see your last month's bank statement for your financial assistance appointment. If you use Venmo, PayPal, CashApp, Zelle, etc. those statements will work as well. To save time and help us get you in quicker, you may upload your bank statement here.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
By clicking "SUBMIT," I acknowledge and hereby certify that all the information provided on this application and information shared verbally is correct and true. I also acknowledge that any information given that is found to be false may disqualify me from consideration. By clicking "SUBMIT," I hereby authorize The Hope Center to release, either verbally or in writing, any and all information, records, or documents pertaining to me to any individuals, organizations, or entities involved in providing community benevolence. Any person releasing said records is authorized to discuss those reports with recipients of financial assistance funds and fellow non-profit organizations; additionally I give permission for The Hope Center to verify my employment and contact my references. Furthermore, The Hope Center is expressly authorized to obtain my records currently on file with any living program or charitable organization and to retain such information in its database. Any information obtained may be used to grant or deny any request made to The Hope Center for assistance. A copy of this authorization has the same force and effect as an original. Once submitted, this application and the copies of any all required paperwork becomes the expressed sole property of The Hope Center and will not be returned to the client.
*
Agree
Do Not Agree
SUBMIT
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