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.
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
1. Do you have legal custody of children you are raising?
Yes
No
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?
Yes
No
7. How did you find out about this program?
Submit
Should be Empty: