2021 IMA Financial Assistance Request Form

Rows	Years	Months
Time at this address:

Additional Household Members

Add all other people/children living in the household. You will need to upload a copy of each person's Social Security Card.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
SSN/TIN
Upload a copy of this person's Social Security Card here:

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Are there additional adults/children living in the household?

Indicate funds received from State/Federal sources:

Who referred you to IMA?

First NameLast Name
Please provide a phone number for this person:
Please enter a valid phone number.Format: (000) 000-0000.
Have you received assistance from IMA before?
Date

MonthDayYear
Date

Please list other agencies you have contacted, the name of the person you spoke to and their response to your request (approved/denied/amount given).

Request Details

Please complete the following information concerning your request:
Briefly explain your request:

What are you requesting assistance for and what is the amount you need?

Utility Company Name you are requesting assistance for:
Please provide your Account Number with this utility:
Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please upload a CLEAR photo of each bill you are requesting assistance with:

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I hereby certify that all the information in this application is true to the best of my knowledge. I authorize Interdenominational Ministerial Alliance (IMA) and their agents to contact the businesses or individual's necessary to verify that the information submitted with this application for financial assistance is true and correct. I understand that the IMA may grant or deny my request based on various factors including but not limited to the accuracy of the information submitted with this application.
Full Name of Applicant

First NameLast Name
Signature
Date

MonthDayYear
Date
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Interdenominational Ministerial Alliance