Giving Grace Grant Application

Giving Grace Grant Application

Please read ALL eligibility and application submission requirements before completing the application. Please include all required documentation with your submission. Consideration of your application will be delayed if incomplete documentation is received. If you need assistance, please contact The Grants Committee at AGSMGrants@americangoldstarmothers.org
AGSM Member's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Note: You must be a Member in good standing for a minimum of 1 year at the time of application.
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Have you ever applied for or received a grant from American Gold Star Mothers, Inc.? (Prior grant receipt will not affect eligibility for the Giving Grace Grant.)*

YesNo
If yes, when? (Please enter month and year)
Have you ever applied for or received a grant from American Gold Star Manor? (Prior grant receipt will not affect eligibility for the Giving Grace Grant.)

YesNo
If yes, when? (Please enter month and year)

Hardship or Emergency Information
Have any of the below impacted you and your household? (Check all that apply)*

A member of the household is currently unemployedA member of the household is currently experiencing illnessThere is an imminent threat to the household’s housing stability (for example, potential for eviction due to non-payment of rent or utility shut-offs due to non-payment).Primary residence damage due to a federal or state declared emergency. (for example, hurricane, flooding, tornado, etc.)A federal employee currently furloughed and/or receiving government funded assistance such as SNAP(Food Stamps)
Are you requesting Dues Assistance

I am requesting Dues Assistance in addition to hardship or emergency assistance.I am requesting ONLY Dues Assistance
Number of individuals in your household? (Include all family members, children/grandchildren, roommates, or others who reside in the same residence.)*
Please briefly describe the hardship or emergency your household is experiencing.*

Landlord/Mortgage Company, Utility Company, or other Debt Holder Contact Information

(List each debt separately)
Debt #1 Name of Company/Debt Holder*
Debt #1 Type of Debt (e.g. Mortgage/Rent, Utility, Medical, if other please describe)*
Debt #1 Amount of assistance requested*
Debt #1 Contact Name
Debt #1 Company/Debt Holder Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Debt #1 Company Email
example@example.com
Debt #1 Company Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Debt #1 Name on Bill, Lease Agreement, or Mortgage*
Debt #1 Account Number (if applicable)
Are you requesting assistance for another debt?*

Yes (Enter next debt details)No

Debt #2 Name of Company/Debt Holder*
Debt #2 Type of Debt (e.g. Mortgage/Rent, Utility, Medical, if other please describe)*
Debt #2 Amount of assistance requested*
Debt #2 Contact Name
Debt #2 Company/Debt Holder Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Debt #2 Company Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Debt #2 Company Email
example@example.com
Debt #2 Name on Bill, Lease Agreement, or Mortgage*
Debt #2 Account Number (if applicable)
Are you requesting assistance for another debt?*

Yes (Enter next debt details)No

Debt #3 Name of Company/Debt Holder*
Debt #3 Type of Debt (e.g. Mortgage/Rent, Utility, Medical, if other please describe)*
Debt #3 Contact Name
Debt #3 Amount of assistance requested*
Debt #3 Company/Debt Holder Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Debt #3 Company Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Debt #3 Company Email
example@example.com
Debt #3 Account Number (if applicable)
Debt #3 Name on Bill, Lease Agreement, or Mortgage*
Are you requesting assistance for another debt?*

Yes (Enter next debt details)No

Debt #4 Name of Company/Debt Holder*
Debt #4 Type of Debt (e.g. Mortgage/Rent, Utility, Medical, if other please describe)*
Debt #4 Contact Name
Debt #4 Amount of assistance requested*
Debt #4 Company/Debt Holder Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Debt #4 Company Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Debt #4 Company Email
example@example.com
Debt #4 Name on Bill, Lease Agreement, or Mortgage*
Debt #4 Account Number (if applicable)

Required Documentation

For your application to be considered complete, you must upload the following documentation.
You MUST attach copies of documents for every expense for which you are requesting assistance. Acceptable documents include:
- lease agreement
- mortgage statements
- demand or default notices
- eviction notices
- utility bill
- shut-off notice
- medical bill
- other documentation
For Disaster Relief Assistance, You MUST attach copies of documents for every expense for which you are requesting assistance. Acceptable documents include:
- hotel receipt if you were displaced
- temporary accommodations receipt if you were displaced
- repair estimates or receipts for the damage to your primary residential structure and/or vehicle
- other documentation
You MUST also include your homeowners or vehicle insurance declaration page that states your deductible, insurance denial letter, and/or FEMA denial letter.

You MUST attach a complete copy of your last two bank statements. (You may redact your account number or other personally identifiable information.) (Multiple documents may be attached)

It is preferred that all documents be submitted in PDF format.
*

Cancelof

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to an award of Grant funds, I understand that false or misleading information in my application or interview may result in legal action. *By entering my name in the signature box below, Applicant acknowledges that it has the same validity and meaning as a handwritten signature and is the legally binding equivalent to a handwritten signature.
Please type Applicant's full name in the box below.
Should be Empty:

Hardship or Emergency Information