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Support Request Form
Please complete the following form to confirm eligibility and request support services from GRACE. A Care Manager will be in touch to schedule your appointment after eligibility and information is confirmed.
Eligibility
Please provide your city of residence to confirm you're within our service area.
City
Please Select
Grapevine
Southlake
Colleyville
Hurst
Euless
Bedford
Keller
North Richland Hills
Richland Hills
Haltom City
Watauga
Westlake
Trophy Club
Roanoke
Fort Worth
Flower Mound
Lewisville
None of the above
City of residence and/or occupation
Zip Code
Please Select
75028
75067
76040
76177
76244
76137
75022
None of the above
Zip Code of residence and/or occupation
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You're In!
You are within our service area and eligible for services! Please complete the following information and a Care Manager will be in touch with you shortly to schedule an appointment.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
School District
*
School District Zip Code
*
Services of Interest (Check all that apply)
Food Pantry
Emergency Assistance
Community Clinic
Mentorship Housing
Senior Services
Back to School Supplies (Summer Only)
Christmas Cottage (Winter Only)
Other
Required Documents for Service
Please upload as many of the documents below as possible to expedite our process in getting you the help you need.
Proof of Income
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Please upload paycheck stubs for the previous 30 days for all working adults in the household
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Current Bank Statement
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Copies of All Financial Assistance
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Choose a file
This includes Food Stamps, TANF, Child Support, SSI, Social Security, Unemployment, Worker's Comp, Disability, and Retirement documents.
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Copy of Current Lease
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Choose a file
Complete copy of lease should be signed by a tenant and landlord. If you do not have a copy of your current lease, please request a Residence Verification Form at your visit.
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Current School Registrations / Report Cards
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Proof of enrollment in some form is required for all school-age eligible children.
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Other Documents
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Please upload any other documents you feel helps explain your financial crisis here (i.e. Medical diagnosis papers)
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ATTENTION:
All documents must be submitted to meet with a Care Manager. If you are unable to upload all documents here, please print and supply any remaining documents at your visit to receive maximum support.
Social Security Number(s)
Please list SSN for all family members seeking service. (A social security number is not required to receive assistance)
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