Hardship Grant Application

Hardship Grant Application
Name*

First NameLast Name
Email*
example@example.com
Phone Number (mobile)*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County*
Green Country Member #
Credit Union Reference - this is someone on staff at the Credit Union who can attest to your need and/or member status.
Reference Name*
Demographic Identification*
Current Household Income
Financial Hardship - Select all that apply.*

Unable to work due to illnessFamily members unable to work/school due to illnessLoss of incomeIncreased medical expensesDelinquent on loansDelinquent on billsOther
How will this grant benefit you. Please include the dollar amount that you're seeking. *
All of the information collected in this form is necessary in gathering information about me, as the applicant for the grant that I am applying for. I understand that by filling out this application I am not guaranteed any grant funding as the program is limited. I also understand that I have to meet certain federal grant requirements to be eligible.

The information shall be used and referred for purposes of knowing, understanding, and validating the information in relation to the qualifications for which the application requires. The information provided will be held by Green Country Federal Credit Union and shared only with the US Department of the Treasury for auditing purposes.

Green Country Federal Credit Union shall treat all personal information with the utmost confidentiality in line with the standards of data protection required.
Conformity and Acknowedgment*

I understand the information above.
Name*

First NameLast Name
Signature*

Clear
Through programs with the CDFI Fund, Green Country FCU may offer grants or loan programs from federal funding sources. No person in the United States shall, on the ground or race, color, national origin (including limited English proficiency), be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance. Additionally, no otherwise qualified individual with a disability in the United States shall, solely by reason of her or his disability, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance. Green Country FCU is an Equal Housing Lender.
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