Project Hope Emergency Assistance

Income and Expenses
Income
Gross Monthly Income*
Includes employment and any additional income received through child support, Social Security, etc.
Have you applied for financial aid from us before?*

YesNo
Expenses
Rent/Mortgage*
Utilites*
Water, Electric, Gas
Phone*
Land and Cell
Food*
Vehicle*
Car payment and insurance
Cable/Internet*
Other Expenses*
Total Expenses

All determinations will be evaluated on a case-by-case basis, based on availability of funds and circumstances
Describe the nature of the emergency:*
Describe how assistance will help handle the current problem:*
How has the applicant tried to handle the problem? Mention other assistance accessed recently:*
Comments / Recommendations:*
Request
We know those in our community have medical bills that can prevent them from paying a bill on time, or even at all. Our Project Hope program can help those members of our bleeding disorder community with a utility bill, rent, or food. Please note we cannot help with medical bills themselves. We would require you to fill out the application and send in a copy of the bill that you need help with. Those who have come to our events in the last year will receive $500 and those who do not attend our events will receive $250 that will go towards the bill they have submitted. It can be more than one bill.

Approval for financial assistance is contingent upon the availability of sponsorship funds. As we rely on generous sponsors to support this program, the timing of available funding can vary.
Type of Assistance Requested

HousingUtility billFood / GasOther
Total Amount Requested*
You will have an opportunity to add additional request to total the full amount of the request.

Payment to Vendor Information
Payment to be issued to: (Should be landlord, mortgage or utility company or other qualified vendor)
Vendor Name:*
Account Number:*
Address to mail payment:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please include a copy of the mortgage coupon, rent receipt, or current bill that is to be paid.
Current bill that you are requesting payment for:*

Cancelof
Amount you would like paid:*
Do you have an additional invoice to add?*

YesNO
Current bill that you are requesting payment for:*

Cancelof
Amount you would like paid:*
Do you have an additional request for a food giftcard?*

YesNo

Food or Gas Card

We will email or mail out a Walmart, Kroger, or BP gift card.
Which gift card would you like?*

WalmartKrogerBP
Amount you would like on the card:*
Would you like the gift card emailed or mailed to your home address?*

Emailed (should receive same day or next)Mailed (could take up to a week to receive)
Email address in which you would like to receive the ecard:*
example@example.com
Mailing address in which you would like to receive the gift card:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Assistance Requested*

YesNo

Signature
***All sections must be filled out and supporting documents must be attached prior to processing***

Release of Infirmation/Applicant Attestion: I certify that the information I have provided is true and correct. I consent to the release of pertinent information contained in this application the Tennessee Hemophilia & Bleeding Disorders Foundation, other social service agencies which distribute emergency financial assistance, the company or individual to treceive funds as necessary to complete the services to my household, or to provide statistics on emergency assistance, or as a guard against duplicate assistance. I also consent to release of patient information to the federal government and those utility companies which require documentation of receipient's funds.
Signature*

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General Information