Application for Financial Assistance

Household Members/Dependents

(List income for each member. If a dependent, please list age.)
Household Financial Resources:

Include all financial resources that your household receives on an monthly/annual basis, including:
- pay/wages,
- disability,
- social security and unemployment benefits,
- self-employment, and
- other monies received by the household.
Are you the only person living in the household?*

YesNo - Enter each additional member in the household on the next page.

Provide the following information for each additional person living in the household.
Supporting Verification Documents are required for all individuals living in the household. Any of the following will be accepted.
- A copy of SSI benefits statement, if applicable.
- A copy of your two (2) most recent pay statements for all income sources.
- A copy of your Unemployment approval or denial letter.
1. Name
1. Income amount for the person above.
Supporting Documentation is required.
1. Relationship/Age for this person:
2. Name:
2. Income amount for the person above.
Supporting Documentation is required.
2. Relationship/Age for this person:
3. Name:
3. Income amount for the person above.
Supporting Documentation is required.
3. Relationship/Age for this person:
4. Name:
4. Income amount for the person above.
Supporting Documentation is required.
4. Relationship/Age for this person:
5. Name:
5. Income amount for the person above.
Supporting Documentation is required.
5. Relationship/Age for this person:

Public Benefits/Income
Do you receive any of the following?*

SSI/Disability (attach document, include amount below.)Unemployment Benefits (attach document)I do not receive any public benfits
Your Monthly Income Information:

This information is required for consideration. Complete each of the following that apply.
Name of Employer:
Job Title:

Enter 0 if you do not have income for that section. Each section with an amount will require a document to be attached below. *

	Amount Totals
How much is you monthly paycheck form your job?
How much do you receive in Unemployment?
How much do YOU get from the other people living in the house each month?
How much do you get from other sources each month?
Total: The above totals added up here: -->

If you are unemployed since, when was the last date you worked?

MonthDayYear
Date
Describe what other jobs you do for income that you recorded above:

Attach the following items:

At least one of the following is required for application to be considered.
Applications that do not include the following items, supporting the income you reported above, will be DENIED.
Most Recent Check Stub - Must be able to read your gross income on the document.

Cancelof
Lay-Off/Unemployment Documents

Cancelof
SSI/Disability Documents

Cancelof
Other:

Cancelof
Applications that are missing information will not be considered.

I am attesting that all the information on this form is true and accurate by my signature below.

Participant is responsible for all fees due until application approval is received from Program Director.
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Household Members/Dependents