Financial Application

Financial Assistance Application

Financial Services Aaliyah Is Healed Foundation can assist with:

-Medical Bills

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

-Rent/Mortgage

-Fuel cards

-Medication/Prescription payments

What to expect.

After your application has been received, a staff member or volunteer will contact you via phone and interview you.

· Please be prepared to explain what created your crisis and to discuss all household income and expenses.

· 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 to 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, SNAP or other assistance award letter.

· 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. AIHF only pays rent to the actual property owner and this information is verified on the Tarrant County GIS.

Name*

First NameLast Name

Date of Birth*

Date

Email

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Email

example@example.com

Ethnicity/Race

Gender

Marital Status

Employment Information of Applicant: Please list Employer name and contact Information)

Individuals living in household:*

Monthly Income:

Are you a resident of Tarrant County?*

YesNo

Do you need assistance with Rent/Mortgage?*

YesNo

For help with Rent, please list who the landlord is, their contact number, and the address of the rental you are moving into:

Eviction Notice (a copy of the eviction notice will be required- you can attach the notice at the end of this form)*

YesNo

For help with an Eviction Notice, please provide the landlord's name, phone number, and the court date listed on the eviction:

Utility Disconnect Notice (a copy of your disconnect notice will be required and can be attached at the end of this form)*

YesNo

For help with a Utility disconnection, please provide the name of the utility company, the account number, and the name of the person the account is in: (*you must contact the utility company and set up a payment plan prior to applying for assistance*)

Do you need assistance with Medical Bills?

YesNo

Please provide name of hospital or medical clinic in which payment is owed to. (a copy of your statement will be required and can be attached at the end of this form

Do you need assistance with transportation fuel?

YesNo

Unexpected expenses (ex: car repairs, home repairs, out of pocket medical expenses, etc.- receipts will be required)*

YesNo

Employer decreased my hours and as a result my monthly income has decreased (pay stubs will be required to show decrease)*

YesNo

Loss of employment*

YesNo

Have you applied for unemployment assistance?*

YesNo

Are you looking for new employment? (Proof of job searches may be required)*

YesNo

Something else has caused my crisis:

Attach a copy of your Eviction Notice or Utility Disconnect Notice here.

Browse Files

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

Browse Files

Attach any medical bills here.

Browse Files

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

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

Signature*

Aaliyah Is Healed Foundation

What type of financial assistance do you need?

What caused your financial crisis?