MLK Sr. Collaborative Financial Assistance Application

Please Read Before Submitting This Application

MLK Sr. Collaborative is committed to supporting individuals and families experiencing a temporary financial hardship based on available funding and documentation. Please review the information below carefully before completing this application to ensure this program is a good fit for your current situation.
Eligibility:

• Adults that reside within the Greater Atlanta region which includes: the City of Atlanta, Cherokee, Clayton, Cobb, DeKalb, Douglas, Fayette, Forsyth, Fulton, Gwinnett, Henry and Rockdale counties. • Documented financial need • An unexpected critical need• A social service assessment of need and circumstance • At least three months of positive payment history • Proof of employment and verifiable income
*Assistance is capped at a maximum of $1,200 toward rent or mortgage arrears or a maximum of $600 toward utilities. Requests exceeding this amount cannot be approved, even if all other eligibility criteria are met. The Collaborative releases funds to the landlord, mortgage company or utility provider by check via US Mail.
*If you have received financial assistance from the MLK Sr. Collaborative in the last 12 months, you are NOT eligible for financial assistance until the 12-month lapse date of previous award.
*Complete documentation is required. Applications that are incomplete, missing documents, or submitted too close to an eviction, foreclosure, or utility disconnection date may be denied or deferred. Must supply: State ID, lease/mortgage document, ledger, W9, proof of income, bank statements, hardship documents, and utility bill PDF.
*Application Review: Please allow 5–10 business days after submission for initial review and follow-up. Applications are reviewed in the order received while funds are available. Submitting a complete application does not guarantee assistance.
*This program is not designed for last-minute eviction prevention. It is designed to address temporary financial hardship, not recurring or unresolved instability. Requests submitted very close to an eviction or court date may not allow sufficient time for review and processing. If you need emergency assistance, we encourage you to contact United Way 2-1-1 or findhelp.org for a current list of resources available in your area.
Submitting an application does not guarantee funding or immediate assistance.

What expenses can this program assist with?
• Housing (must have a lease agreement or mortage)
• Utilities
• Transportation (MARTA *Workforce or Medical Need* only)
• Food
We cannot assist towards:
• Credit Cards
• Personal and Student Loans
• Taxes
• Alimony or Child Support
• Tuition
• Life Insurance
• Storage

• Hotels, Extended Stays, Short-Term Rentals (I.E. Padsplit, Air BnB, Etc.)
• Business Expenses e.g.: union dues, licenses
• Pet Expenses
• Burial or Funeral Expenses
• Prescription Drugs or Medical Debt
• Travel Expenses

Martin Luther King Sr. Community Resources Collaborative

RELEASE OF INFORMATION AUTHORIZATION FORM
Purpose of Authorization
To facilitate access to supportive services and community resources provided or coordinated by the Martin Luther King Sr. Community Resources Collaborative ("the Collaborative"), I voluntarily authorize the release, exchange, and use of personal information about myself and/or my family.
Use of Information:
1. This authorization is granted exclusively for the Collaborative’s use in assessing eligibility, delivering services, coordinating care, and administering benefit programs for me and/or my family.
Consent to Release and Exchange Information:
2. I authorize any individual, agency, institution, or organization to disclose, release, and allow inspection and copying of records pertaining to me and/or my family to the Collaborative. This includes, but is not limited to, social, economic, housing, educational, and employment-related records.
Redisclosure to Partner Agencies and Government Entities:
3. I authorize the Collaborative to share information about me and/or my family with its officially approved service partners, as well as relevant local, state, and federal agencies. This includes the use of electronic data matching systems that may compare my records with other government or institutional databases for the purpose of verifying eligibility and coordinating benefits.
Digital Communications:
4. I consent to the Collaborative communicating with me via email, text message, phone, and other electronic methods as necessary for service coordination. I understand that while reasonable security measures will be taken, digital communications may not be fully secure and could be accessed by unauthorized third parties.
HIPPA- Related Notice (If Applicable):
5.HIPAA-Related Notice (If Applicable): I understand that if my information includes protected health information (PHI) governed by the Health Insurance Portability and Accountability Act (HIPAA), such disclosures will comply with HIPAA regulations. I acknowledge that this form is not intended to replace a specific HIPAA authorization if one is otherwise required.
Release of Liability:
6. I release all persons, agencies, and institutions from any legal liability for releasing information in accordance with this authorization.
Certification
Printed Name of Applicant:

First NameLast Name
Printed Name of Spouse/Legal Guardian (if applicable):

First NameLast Name
Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

General Information
Applicant Date of Birth

MonthDayYear
Gender Identity
Race/ Ethnicity
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Section 1: Household Information
# of Adults (18 yrs+ old) in household:
# of Children (0-17 yrs old) in household:
Applicants Gross Monthly Income (before taxes)
Household Gross Monthly Income (if same as above, re-enter totals)
What is your employment status?
Section 2: Housing Information
Please select one:

Other
Landlord/Property Manager Name: (if requesting rent/mortgage assistance)
Landlord/ Property Manager Phone: (if requesting rent/ mortgage assistance)
Please enter a valid phone number.Format: (000) 000-0000.
Landlord/ Property Manager Email: (if requesting rent/mortgage assistance)
example@example.com

Utility MUST be in applicant name to be considered.
Utility Provider/ Account Number
Utility Provider/ Account Number
How much do you have to put toward your balance(s) owed (arrears)?

Hardship Statement

A hardship letter explains the circumstances which makes you unable to keep up with your debt/payments. This letter provides specific details such as the date the hardship began, the cause, and how long you expect it to continue. In your hardship letter, you should include a detailed description of the type of assistance you are requesting and how you foresee returning to self-sufficiency. Finally, this statement should be personalized, original, and direct.
Please provide a hardship statement.

File Upload

Cancelof
Thank you for your time in completing this application for assistance. Due to high demand, we are unable to provide individual status updates for applications that do not meet eligibility criteria.
Certification and Signature
I certify that the information provided is accurate and complete to the best of my knowledge. I understand that providing false information may result in denial or termination of assistance.
Applicant Initial
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

State ID	2 Bank Statements
Utility Bill	Seperation Letter/ Offer Letter
Check Stubs/ Award Letter	Supporting Documents of Hardship

State ID	Seperation Notice/ Offer Letter
Lease	2 Bank Statements
Ledger	Notice to Vacate/ Eviction Notice
Check Stubs/ Award Letter	Supporting Documents of Hardship

Please Read Before Submitting This Application

Eligibility:

Submitting an application does not guarantee funding or immediate assistance.

What expenses can this program assist with?

We cannot assist towards:

Purpose of Authorization

Use of Information:

Consent to Release and Exchange Information:

Redisclosure to Partner Agencies and Government Entities:

Digital Communications:

HIPPA- Related Notice (If Applicable):

Release of Liability:

Certification

General Information

Section 1: Household Information

Section 2: Housing Information

Hardship Statement

Thank you for your time in completing this application for assistance. Due to high demand, we are unable to provide individual status updates for applications that do not meet eligibility criteria.

Certification and Signature