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Application for Financial Assistance
Are you a case worker from a partner agency or an Arlington county resident?
*
I am a case worker from a partner agency.
I am an Arlington county resident.
Type the name of your organization
Staff email
example@example.com
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Document Checklist
The documents below are REQUIRED to determine residence and income eligibility. Failure to submit the required documents will automatically void the application.
Partner Organizations:
For Individuals:
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Client's Demographics
Type the full name (as it appears on the ID submitted with the application).
First Name
Middle Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Select the gender:
*
Please Select
Female
Male
Transgender
Non-binary
Select the race (choose all that apply):
*
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Select the ethnicity
*
Please Select
Hispanic or Latino
Non-Hispanic or Latino
Other
Phone Number
*
-
Country Code
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Role in the household
*
Please Select
Head of household
Parent
Other Adult
Child
Select all that apply:
Disabled
Veteran
Refugee
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Household Information
Other household members
Full name
Date of birth or age
Gender
Disabled
Veteran
Race
Ethnicity
Partner or spouse
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Hispanic or Latino
Non-Hispanic or Latino
Other
Child 1
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Hispanic or Latino
Non-Hispanic or Latino
Other
Child 2
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Hispanic or Latino
Non-Hispanic or Latino
Other
Child 3
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Hispanic or Latino
Non-Hispanic or Latino
Other
Child 4
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Hispanic or Latino
Non-Hispanic or Latino
Other
Other adult
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Hispanic or Latino
Non-Hispanic or Latino
Other
Other adult
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Hispanic or Latino
Non-Hispanic or Latino
Other
Other adult
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Hispanic or Latino
Non-Hispanic or Latino
Other
Total number of adults in the household
*
How many adults aged 60 or older included in the total number of adults in the household?
*
If none, type 0.
Total number of children 17 years of age or younger
*
If none, then type 0.
Household income sources
*
Full time employment
Part time employment
Federal Disability Income / Supplemental Security Income
Unemployment Insurance
Social Security
Retirement Pension
Alimony / Child Support
Other
Total number of people in the household
Grand total is automatically calculated.
Household Income
*
Please Select
Under $20,000
$20,000-$35,000
$35,000-$50,000
$50,000-$75,000
Over $75,000
Household AMI %
*
Please Select
Under 50% AMI
Over 50% AMI
Under 80% AMI
Over 80% AMI
Refer to the Arlington County FY 2024 AMI Table
Arlington County FY 2024 AMI Table
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Fund Request Information
Date
-
Month
-
Day
Year
Date
What need is this request covering?
*
Ex. Rent, Utilities, Childcare
Request amount- Must not exceed $400
*
Reason(s) for requesting assistance for the expense:
*
Loss of income/employment/
Increased medical costs
Increased utilities
Unexpected expenses
Loss of housing subsidy
Other
Vendor name
*
Payment will be made to this business, entity. Please confirm you have submitted the correct information.
Mailing address for payment
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Memo for Check
*
If you have any concerns about payment mailing, please email dougherty@arlingtonthrive.org
Partner Organizations: Please upload up-to-date versions of the following documents into the File Upload field below. If you fail to upload any of these documents, your request will be denied
For Individuals: Please upload up-to-date versions of the following documents into the File Upload field below. If you fail to upload any of these documents, your request will be denied.
File Upload
*
Browse Files
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