Be A Jewel, Inc. - Assistance Application
Please complete the following application for assistance. Your request will be reviewed, and you will be notified of the Fund’s decision. You must complete the application in its entirety.
Street Address Line 2
State / Province
Postal / Zip Code
1. Do you have legal custody of children you are raising?
If "Yes": What benefits do you receive from the State?
If "No": Do you receive any government assistance? What type?
2. What assistance/grant are you requesting to help provide for children in your care?
3. How long have you had the child(ren) in your care?
4. If you don’t have custody, who can verify that you are responsible for the minor(s) in your care? (i.e., School, church, counselor, etc.)
5. How many children live in your household?
6. Do you receive a rent subsidy or live in low/moderate income housing?
7. How did you find out about this program?
Should be Empty:
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