Compassion In Action

Compassion In Action

Apply for one-time financial assistance for specific needs, including rent or landlord payments, electric or utility bills, and other essential expenses. Funds are paid directly to vendors (landlord, electric company, etc). All information is confidential.
Please acknowledge the following:
Submission Type

Please indicate if you are applying for yourself or on behalf of someone else.
Are you completing this application for yourself or on behalf of someone else?
- Your Full Name
  
  First NameLast Name
- Your Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Your Email Address
  example@example.com
- Your relationship to the applicant
- Have you received permission from the applicant to share her information and submit this application?
- Applicant Full Name
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
  Date-Eligibility is limited to individuals age 18 and older, with emancipated youth taken into special consideration
- Applicant Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Applicant Email Address
  example@example.com
- Applicant Home Address
  
  Street Address
  
  Street Address Line 2
  CityState / ProvincePostal / Zip Code
- Number of adults (anyone over the age of 18) in the household
- If more than 2 adults, please provide explanation:
- Number of children in the household
- Monthly household income (approximate)
- Employment status
  
  Other (explain)
- Employer
- Are you currently receiving any assistance? (Select all that apply)
  
  Other (describe)
- Type of need assistance is requested for
- Total amount needed
  Requests will be reviewed thoughtfully and awarded to the best of the program’s ability based on available funds. The amount requested may not be granted in full. No request may exceed $500.
- Vendor Name
- Vendor Address
  
  Street Address
  
  Street Address Line 2
  CityState / ProvincePostal / Zip Code
- Vendor Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Vendor Email (if available)
  example@example.com
- Account Number or Reference Number (if applicable)
- Describe your need and how this assistance will help. Additional details are encouraged, including prior efforts to resolve the need, resources already exhausted, and any other assistance you have applied for (with approximate dates and outcomes).
- Evidence of ownership of the bill is required. The documentation you upload MUST clearly show: Your full name, the full account number, and the total outstanding balance due. Acceptable documentation includes a complete invoice, bill, statement, or other official proof of the amount owed. You MUST upload the entire bill or statement; partial documents or screenshots showing only a portion of the bill will not be accepted. Failure to provide all required details and the full document will result in a denial of your application.
  
  Cancelof
- Has the applicant received assistance from CIA before?
  
  Yes (please explain)
- Is the applicant able to contribute any portion toward this need?
  
  Yes (please specify amount)
- How soon is this assistance needed?
- Please share anything else you would like us to know about your situation. This is your time to provide additional information or explain circumstances that may not be fully reflected in the application.
- By submitting this application, I confirm the information provided is true and accurate. I understand this form does not guarantee approval and funds—if granted—are paid directly to the vendor.
- Signature of the person completing this form (Typed Name)
- Date
  
  MonthDayYear
  Date
- Disclaimer
  
  All applications are reviewed by the CIA Fund Committee for completeness and demonstrated need. Missing or incomplete information may result in a delay or denial of the application. If you have any questions or need assistance completing this form, please email EmpowHERmentAlliance@gmail.com for more information
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Compassion In Action

Submission Type

Disclaimer