Better Promises Assistance Request Form

Better Promises Assistance Request Form
Request support for rent, food, utilities, clothing, and more. All information is confidential and used only to determine eligibility and connect families with resources.

Better Promises provides limited assistance based on funding availability. Submitting this form does not guarantee assistance. All information is confidential and used only to determine eligibility and connect families with resources.
Applicant Information

Please provide your personal details.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Full Home Address (Street, City, State, Zip)*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Language*
Assistance Requested*

Rent AssistanceFood AssistanceUtility AssistanceClothingHygiene ItemsReferral to other resourcesOther (please specify)
Household Information

Tell us about your household.
Number of adults in household*
Number of children in household*
Names and ages of children (optional)
Are you currently employed?*

Yes, full-timeYes, part-timeNo
Monthly household income (approx.)*
Are you currently receiving any benefits?*

SNAPMedicaidWICSSINoneOther
Housing & Urgency

Tell us about your current housing and urgency of your need.
Do you have a current lease?*

YesNo
Amount past due (if rent/utilities)
Due date / eviction notice date (if applicable)

MonthDayYear
Date
Landlord or utility company name
Landlord/company phone/email (optional)
Describe Your Need

Help us understand your situation.
Please explain your current situation and why you are requesting assistance.*
Document Uploads

Upload supporting documents. Only upload what applies to your request.
Upload photo ID*

Cancelof
Upload lease (if rent request)

Cancelof
Upload current rent ledger or eviction notice (if available)

Cancelof
Upload utility bill (if utilities request)

Cancelof
Permission & Consent

Read and confirm the following statements.
I confirm the information provided is true and complete.*

I confirm the information provided is true and complete.
I understand Better Promises may contact my landlord/utility provider to verify the balance due (if applicable).*

I understand Better Promises may contact my landlord/utility provider to verify the balance due (if applicable).
I understand submitting this request does not guarantee assistance.*

I understand submitting this request does not guarantee assistance.
Signature

Provide your electronic signature.
Type your full name as electronic signature*
Date*

MonthDayYear
Date
Better Promises – Public 501(c)(3) Nonprofit Organization
Address: 12160 Abrams Rd, Suite 109, Dallas, TX 75243
Phone: +1 (214) 238-0512
Email: support@betterpromises.org
Website: www.betterpromises.org
Should be Empty:

Better Promises Assistance Request Form

Applicant Information

Household Information

Housing & Urgency

Describe Your Need

Document Uploads

Permission & Consent

Signature