GROVE CHURCH EMERGENCY ASSISTANCE APPLICATION

ELIGIBILITY

You must be:

over 18 years old and a Portsmouth, VA resident

OR

over 18 years old and a Grove Church member

The residential requirement does not apply for members

Grove Church partners with community organizations, municipal services and utility providers to offer emergency assistance to individuals and families who are experiencing a temporary financial crisis.

Assistance is provided on a limited basis and those needing longer-term assistance are referred to other sources such as the Housing Crisis Hotline, HER Shelter and Union Mission services.

Eligibility for assistance is not guaranteed and documents are required prior to processing and approval or denial.

DOCUMENTS

We need the following documents in order to ensure that you qualify for assistance:

ELECTRICITY

Apply if your service has been disconnected or pending termination with a disconnection date

These documents are needed for a decision to be made:

§ Photo ID - current (not expired), government-issued with the name of the account holder

§ Dominion Energy bill must show the termination notice and date

§ The name on the application must match the name on the bill

RENT | Rental Assistance for Non-Subsidized Housing

Apply if your rent is past due for 1 month and have received a 5 Day Notice to Pay or Quit or Court issued eviction documents with court date

APPLICANTS

These documents are needed for a decision to be made:

§ Applicants cannot be subleasing, living with the landlord or renting from a relative

§ Photo ID - current (not expired), government-issued for each leaseholder

§ Signed Lease Agreement – written lease in client’s name to include terms of lease clearly specified (i.e., leaseholder name/address, landlord name, monthly rent amount, etc.)

§ 5-day Notice to Pay or Quit, Court Summons with appearance date or eviction notice (unlawful detainer) in the applicant’s name.

§ Rental Ledger - with your rental payment history

LANDLORDS | PROPERTY MANAGEMENT

These documents are needed prior to funding:

§ Photo ID - current (not expired), government-issued for private landlords.

§ Current IRS W-9 Tax Form – completed by the Landlord with signature not older than 1 year and a contact phone number and email.

§ Private Landlord must show proof of property ownership such as a Deed or Mortgage Statement in their name.

ALL DOCUMENTS MUST BE UPLOADED BEFORE PROCESSING BEGINS

UPLOAD DOCUMENTS*

ADD jpeg, png, pdf

Please share with us what happened and the reason why you need assistance.*

Are you a member of Grove Church?*

YesNo

Do you live in Portsmouth, VA?*

YesNo

Are you 18 years of age or older?*

YesNo

FIRST NAME

LAST NAME

ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

MARITAL STATUS

MARRIEDSINGLEDIVORCEDWIDOWED

PHONE

EMAIL

example@example.com

YOUR DOMINION ENERGY BILL MUST HAVE A DISCONNECTION NOTICE

DOMINION ENERGY ACCOUNT

DISCONNECTION DATE

HOW MUCH DO YOU OWE?

APPLICANT'S CONTRIBUTION TO THE BALANCE

REQUESTED AMOUNT FROM GROVE CHURCH

NAME OF APARTMENT COMPLEX

NAME OF PROPERTY MANAGER

PROPERTY MANAGER PHONE NUMBER

Please enter a valid phone number.

HOW MUCH DO YOU OWE?

APPLICANT'S CONTRIBUTION TO THE BALANCE

REQUESTED AMOUNT FROM GROVE CHURCH

EMPLOYER

Company Name

Street Address

CityState / Province

Postal / Zip Code

LENGTH OF EMPLOYMENT | YEARS

LENGTH OF EMPLOYMENT | MONTHS

PAY RATE/HOUR

PAY FREQUENCY | BIWEEKLY, MONTHLY

HOURS WORKED PER WEEK

IF NOT EMPLOYED, ARE YOU

UNEMPLOYEDRETIREDGOVERNMENT ASSISTANCE

MONTHLY AMOUNT OF Unemployment Benefit, Social Security, Pension

IF NOT A GROVE MEMBER, WHAT CHURCH DO YOU ATTEND?

HAVE YOU RECEIVED ASSISTANCE FROM GROVE CHURCH IN THE PAST YEAR?

YESNO

HAVE YOU RECEIVED ASSISTANCE FROM ANOTHER AGENCY IN THE PAST 6 MONTHS?

YESNO

LIST ALL THE MEMBERS OF YOUR FAMILY LIVING WITH YOU

By signing below, you agree to the following:

I have read and understand the Grove Church Emergency Assistance fund policy and eligibility requirements. I certify that the information provided on this application is accurate. I give Grove Church permission to verify the information given on the documents submitted for the purpose of determining eligibility for funding. I understand that incomplete applications, withholding information or giving false information will result in the denial of my application.

Signature

DATE

Date

PERSONAL INFORMATION

ELECTRICITY ASSISTANCE

RENTAL ASSISTANCE

EMPLOYMENT INFORMATION