Shelby County Community Golf Charities, Inc.

Shelby County Community Golf Charities

EMERGENCY ASSISTANCE FUNDING REQUEST FORM
Section 1: Applicant Information
Date of Request*

MonthDayYear
Date
Full Name of Applicant*
Street Address*
City*
State*
ZIP*
Phone Number*
Email optional
example@example.com
Are you a U.S. Citizen?*
Are you a Shelby County Resident?*
Section 2: Request for Child Assistance
Is this request for a child?*
If yes: Child's Full Name
If yes: Child's Age
Section 3: Household Information
List everyone living in your household, including age:*

Please list everyone in your household of working age (including teenagers) and their monthly income (Include Name, Age, Income):

Rows	Resident 1	Resident 2	Resident 3	Resident 4
Name
Age
Income

Notes on above residents:
Do you have medical insurance?*
If yes, insurance provider:
If yes, policy number:
If yes, insurance phone number:
Section 4: Employement Information
Employer Name*
Length of Employment*
Position*
Employer Phone:*
Supervisor Name*
Spouse Employment (if applicable):
Employer Name
Position
Length of Employment
Employer Phone:
Supervisor Name
Section 5: Type of Assistance Requested
Please check all that apply:*

Medical BillsPrescription CostFood AssistanceTransportationHousing/Utility AssistanceOther
Mortgage/ Rent*
Automobile*
Telephone*
Medical Bills*
Food*
Gasoline*
Utilities*
Other
* We are unable to pay Credit Card Bills*
Is this an emergency cituation?*
If yes, please describe why this is urgent (e.g., eviction notice, utility cutoff, critical medication):
Do you have a specific due date or deadline for payment or action?*
If yes, when?
Section 6: Circumstance of Need
1. Did your need for assistance result from a work-related situation, injury, or illness?*
If yes, explain:
2. If this request is due to a medical condition injury or diagnosis, please describe the situation and include any supporting medical documentation if available*
3. You are encouraged to include any documentation that you feel would help the committee understand and evaluate your request (e.g., medical records, utility shutoff notices, eviction notices, bills, etc.*

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4. Explain the reason you are requesting assistance:*
5. What steps are being taken to resolve or improve this situation?*
6. How long do you expect your recovery/correction plan to take?*
Section 7: Financial Information
Have you applied for help from any other churches, organizations, or government agencies?*
If yes, list names, dates and results:
Please describe your current financial situation and what led to this request:*
Have you received assistance from SCCC before?*
If yes, when and for what purpose?
How long have you been facing this hardship?*
Do you have family, friends, or community members who are helping you financially or otherwise?*
If yes, explain:
Have you contacted any local resource centers or government programs (e.g., SNAP, LIHEAP, unemployment)? *
If yes, which ones and what was the outcome?
Monthly Income Total (all sources):*
Monthly Expenses (housing, bills, etc.):*
How Did You Hear About Us? (Optional but helpful for outreach)

ChurchHospitalSocial Worker or Case MAnagerFriends or FamilyOnlineOther
Section 8: Consent & Authorization
By signing below, I certify that the information provided in this form is true and complete. I authorize Shelby County Community Golf Charities, Inc. to verify the information provided, including contacting listed Employers, Agencies, or References. I understand that my application may take 30-45 days to process and that funds (if approved) will be disbursed up to 10 days after approval. Approved Funds are disbursed directly to the Vendor, Service Provider, Creditor, or Agency owned. (E.g. Utility Company, Landlord, Hospital Billing Department, Pharmacy, etc It will not be written to the Applicant.

Your information will be held in strict confidence and used only for the purpose of evaluating your request.
Date*

MonthDayYear
Date
Applicant Signature*

Clear
May we contact you for additional information if needed?*
Have you spoken with or are currently working with a board member regarding this request?*
If yes please provide their Name
Section 9: For Office Use Only
SCCC Member Receiving Form
Date Received

MonthDayYear
Date
Committee Review
[] APPROVED
[] DENIED
Date

MonthDayYear
Date
Should be Empty:

Shelby County Community Golf Charities

[] APPROVED

[] DENIED