Financial Assistance Form
This form helps Indiana Wish understand your family's current needs so we can explore available support and resources.
Wish Family Information
Wish Child's Name
*
First Name
Last Name
Primary Contact Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Wish Number (If known)
When did your child receive their Wish?
*
Within the past year
1-2 years ago
3-5 years ago
More than 5 years ago
Not sure
Has your family participated in any Indiana Wish programs or events since the Wish was granted? Please note: Your response to this question will not impact your eligibility for financial assistance or the review of your request.
*
Yes
No
Not sure
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Household Information
Number of adults in household
*
Number of children in household
*
Ages of children
*
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Type of Assistance Requested
What type of financial support are you requesting?
*
Rent or house assistance
Electricity
Gas
Water
Internet or phone
Transportation assistance
Other
Please briefly explain your current situation and why support is needed:
*
How urgent is this need?
*
Immediate (within the next 7 days)
Soon (within 2-4 weeks)
Within the next month
Estimated amount needed
*
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Service Interruptions
In the past 12 months, how many times has your household experienced a utility shut-off or service interruption due to non-payment?
*
None
1 time
2-3 times
4 or more times
Which services were affected?
Electricity
Gas
Water
Internet or phone
Rent/housing stability
Other
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Income & Support Resources
Household income range
*
Under $25,000
$25,000-$50,000
$50,000-$75,000
Over $75,000
Are you currently receiving support from any of the following?
*
SNAP/food assistance
Medicaid/Hoosier Healthwise
Disability benefits
Unemployment
Other nonprofit or community organization
None of the above
Are you currently working with another organization for financial assistance?
*
Yes
No
Upload any relevant documents (utility bill, rent notice, shut-off notice, etc.)
*
Browse Files
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Is there anything else you would like us to know about your family's situation?
I consent to a release of account if needed to pay requested service.
*
Yes
No
Indiana Wish reviews each request carefully. Submission of this form does not guarantee assistance, but helps us understand how to best support our Wish families or connect them with additional resources. All approved funds are paid directly to the service provider or company, not to the applicant. If assistance is granted, the applicant may be asked to provide or authorize the release of account information needed to process payment.
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