Financial Assistance Request Form
This form is intended for use by Kindness Initiative Members. If you are not currently a member and are interested in becoming a member, please fill out the member application form
CONFIDENTIALITY ASSURANCE:
By completing this form you acknowledge that the information you provide will be treated as confidential and used solely for the purpose intended, under review of the FEAC committee at the Kindness Initiative.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you currently receiving any of the following:
*
SSI
SSDI
Pension
EBT / CalFresh / SNAP
VA Benefits
TANF
Jewish Family Services
Hebrew Free Loan
Section 8
NONE
Other
SSI: How much are you receiving from this monthly?
*
SSDI: How much are you receiving from this monthly?
*
Pension: How much are you receiving from this monthly?
*
EBT / CalFresh / SNAP: How much are you receiving from this monthly?
*
VA Benefits: How much are you receiving from this monthly?
*
TANF: How much are you receiving from this monthly?
*
Jewish Family Services: How much are you receiving from this monthly?
*
Hebrew Free Loan: How much are you receiving from this monthly?
*
Section 8: How much are you receiving from this monthly?
*
If "Other": What are you receiving and how much?
*
By signing here, I certify that the information provided above is true.
Are you requesting assistance for any of the following:
*
Housing (security deposit, rent)
Utilities (SDGE, water, sewer, trash)
Medical (one-time emergency)
Transportation (one-time auto repair) - 2 quotes from different vendors required
Other
How many times have you met with Case Management in the last 3 months?
*
Housing: How much are you currently paying monthly in rent?
Utilities: How much are you currently paying monthly in utilities?
Medical: How much are you currently paying monthly in medical bills?
Transportation: How much are you currently paying monthly for transportation? NOTE: 2 quotes from different vendors are required for mechanic work.
If "Other": What are you receiving and how much?
*
Kindness Initiative does not provide funding for medical treatments, medications, legal fees, or personal debt due to liability and safety considerations. Additionally, Kindness Initiative cannot reimburse expenses without verifiable documentation (such as itemized receipts) or costs that fall outside the scope of our primary mission. *Please note it is our policy that payments must be paid directly to the vendor.*
Please describe your financial need (see example): "I am short on rent, my rent is $1200 total and I am short $200. I need to pay my rent by (date), screenshot of rent bill is attached." Example includes exact dollar amount, when the payment is needed and where the payment is going.
*
0/200
Amount being requested:
*
Projected length of time for assistance needed:
*
Please upload any supporting documents such as quotes, receipts, bills, etc.
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By submitting this application for financial assistance, I understand that this request will be reviewed by the Funding Evaluation & Allocation Committee at the Kindness Initiative and a determination will be made within ten business days. I acknowledge that Kindness Initiative reserves the right to award or deny any request for financial assistance.
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By submitting this application for financial assistance, I understand that this request will be reviewed by the Financial Assistance Committee within ten business days. I acknowledge that Kindness Initiative reserves the right to award or deny any request for financial assistance. Initials Below:
*
Once all documentation is received, you will be notified by the Financial Assistance Committee within 3 business days. Initials Below:
*
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