Form

Name

First NameLast Name

Address

Street Address

CityState / Province

Postal / Zip Code

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Requested Amount

(note: Any individual receiving over $599.00 will be issued a 1099) Grants will be paid directly to a vendor or service provider whenever possible. Receipts may be requested under certain circumstances.

Purpose of Request:

Household Members

Rows	First and Last Name	DOB	Student - Y/N	Employer
1
2
3
4
5

Monthly Household Income

Rows	Amount received
Monthly Gross Income
Benefits (SS/DHHS/VA)
Food Stamps
Disability income
Rental Income
TANF
Child Support received

Monthly Household Expenses

Rows	Amount paid
Rent/Mortgage
Monthly Utilities
Car payment
Food
Medical
Gas/Car expenses
Child Support payments

Community Resources you have reached out to

Rows	Agency	Amount Requested	Decision/Granted
1
2
3
4

If you have no income, who is assisting you with your expenses?

Household Member(s) with health insurance

Rows	Name:	Insurance Co name:
1
2
3
4

Are you willing to reach out to other community resources

Please provide any additional information or explain any special circumstances that you feel will help C.A.R.E. in their decision about this request.

Do you agree to allow C.A.R.E. to make referrals to other community resource agencies on your behalf and/or to contact other agencies as recommended by C.A.R.E.?

Would you agree to volunteer at a C.A.R.E. event to help pay if forward?

*Repayment of this grant in any amount will be utilized to assist others with a hand-up*

I hereby make application for assistance from C.A.R.E. and certify that this information is correct and true to the best of my knowledge. I authorize C.A.R.E. to futher discuss my request with other community agencies that may be able to assist me. I also authorise C.A.R.E. to verify or obtain information that is relevant to this request for assistance.

Applicant Signature

Date

C.A.R.E. Application for Assistance