Rose Francis Foundation Emergency Financial AssistanceApplication
Welcome to Rose Francis Foundation Financial Assistance Fund. We created this fund to support the immediate and emergency financial needs of our community members. Our fund is 100%funded by community donations and grants. With that said, availability of funds is solely dependent on our funders, being community donations and grants.Rose Francis Foundation was created to fill the gaps faced by mothers, parents, children, and individuals with intellectual and developmental disabilities. Therefore, our Emergency Financial Assistance Fund seeks to prioritize individuals within our community that live within the intersections of the identities listed above. Although we will make our target population a priority that does not disqualify those who live outside of the listed above identities from being eligible or possibly receiving access to Emergency Financial Assistance Funds. We will disperse funds based on the following factors; fund availability and priority. Please use our unique needs assessment tool below to identify who will receive priority during fund disbursement given the pool of applicants.Please reach out to ryann@rosefrancisfoundation.org for additional question/information. Please follow us on all major social media @therosefrancis for updates about services.
IMPORTANT INFORMATION
Before moving forward, please complete our new client Intake Form here;https://form.jotform.com/242035403628046. failure to do so will result in no review of your following application.
Contact Information
In this next section, please provide your contact information.
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Preferred Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Payment Information
In this next section, please provide your payment information.
Zelle Username (Required)
*
Zelle Account Photo Confirmation
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Driver's License, Birth Certificate, or Passport
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Demographic Information
In this next section, please provide your demographic information. The following information about identity labels such as race, gender, age, and parental status isnot required. This information is collected to identify who we are serving, and who requestssupport based on demographic data collected in this form. Additionally, you will not receivedisbursement based on demographic information you provide, but based on Rose FrancisFoundation Priority Disbursement Tool that aligns with our mission and vision as an organization.
Which of these best describes you?
*
Mother
Father
Guardian
Adult without Children
Family Status
*
Please Select
Single Parent with Children under 18
Adult with no Children under 18
Two Parent Household with children under 18
Two Parent Household with no children under 18
Expectant Single Parent
Expectant Two Parents
What is your age?
*
18-25
25-40
40-60
60+
Please select which best describes you.
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latino, or Spanish Origin
Middle Eastern
Native Hawaiian or Pacific Islander
White
Other:
What is your yearly income?
*
$0-25,000
$25,000-40,000
$40,000-65,000
$65,000 and up
Please upload one of the following; most recent pay stub, last three months bank account statements, and/or last year's tax form.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Select forms of monthly income
*
Employment
Government Assistance
Social Security
Other:
Family size including Primary Applicant
*
How many children do you have that are under the age of 18?
*
0
1
2
3
4
5
6
7
8
9
10+
What are the ages of all of your children under the age of 18?
*
Others Living in Home (Required)
Please provide the Birth Certificates, Licenses, and/or Passports of other living in the home including partners, children, etc
Adult 2: Birth Certificates, Licenses, and/or Passports
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Adult 3: Birth Certificates, Licenses, and/or Passports
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Adult 4: Birth Certificates, Licenses, and/or Passports
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Child 1: Birth Certificates, Licenses, and/or Passports
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Child 2: Birth Certificates, Licenses, and/or Passports
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Child 3: Birth Certificates, Licenses, and/or Passports
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Child 4: Birth Certificates, Licenses, and/or Passports
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Child 5: Birth Certificates, Licenses, and/or Passports
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Child 6: Birth Certificates, Licenses, and/or Passports
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Utility Assistance Notice
Please note that if you intend on the assistance to be used for utilities, you will be referred out to the following local and state resources; NC DHHS Low Income Energy Assistancehttps://www.ncdhhs.gov/divisions/social-services/energy-assistance/low-income-energy-assistance-lieap, Crisis Intervention Program | NCDHHShttps://www.ncdhhs.gov/divisions/social-services/energy-assistance/low-income-energy-assistance/crisis-intervention-program
What will the disbursement be used for?
*
Housing
Utilities
Debts
Other:
If the reason is not listed above, please list here;
*
How much do you need?
*
Please provide a proof of financial need
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Anti-Discrimination Policy
Rose Francis Foundation is committed to equal Emergency Financial Disbursement opportunityand does not discriminate in the terms, conditions, or privileges of Emergency FinancialDisbursement on account of race, age, color, sex, national origin, physical or mental disability, orreligion or otherwise as may be prohibited by federal and state law.
Important Disbursement Information
As previously mentioned, our Emergency Financial Assistance Fund is 100% funded bycommunity-based donations and grants. Following the accrual of donations or grants over a 6month period, we are simultaneously dispersing funds up to $500 to selected applicants on amonthly basis (the first of every month). During our monthly timeline for disbursement we areanalyzing Emergency Financial Assistance Funds Applications with our valued Board Membersand Employees to select and deny candidates based on our Hardship Tool, availability of funds,and based on applications we are identifying ways to best support applicants within our meansand capacity as an nonprofit 501(c)(3).
Reapplication Policy
Following the acceptance of your application and disbursement you will not be able to re-apply for two months following your previous application submission date. If your application is not accepted and funds are not disbursed any emergency financial assistance you will be eligible to re-apply three weeks following your last application submission date.
Do you agree to follow thereapplication policy as it is stated above?
*
Continue
Continue
Should be Empty: