Application for Assistance Please note all assistance will be paid directly from bills and invoices. Applicant 1 First Name *Applicant 1 Last Name *Applicant 2 First NameApplicant 2 Last NamePrimary Phone *Mobile PhoneIf not your Primary PhonePrimary Phone TypeHomeMobilePrimary Email Address *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *List all members of household and ages: *FinancesTotal Monthly Household Income *USDTotal Monthly Rent/Mortgage *USDUtilities (electric) *USDGas (home) *USDCable/Internet/Home Phone *USDGroceries *USDMobile Phone(s) *USDCar Payment/Rideshare *USDAuto Insurance *USDGas (car) *USDMedical *USDRX *USDOther Monthly Expenses not Listed AboveExplain what caused your hardship and the list expenses that have been a factor in your current situation. *What is the total amount of your request? *USDList the bills and expenses you are asking for assistance with. Be specific and itemize with dollar amounts. One expense per line, please. *Please list any agencies/individuals that you have applied to for assistance, and how much was given to you. *Please list any other agencies/individuals that have provided you with any other type of assistance. *Additional InformationAre you related to any Your Home Team Cares Board Members? *YesNoName of Board MemberReferencesPlease provide a name of someone as a reference who has knowledge of your current situation.First Name *Last Name *Phone # of Reference *Relationship to Reference *Would you like to add a second Reference? *YesNoReference 2 First Name *Reference 2 Last Name *Phone # of Reference 2 *Relationship to Reference 2 *First Name of Person who Referred You *Last Name of Person who Referred You *Phone # of Person who Referred You *Relationship to Person who Referred You *AgreementApplicant acknowledges that after the application is received there will be a phone interview and all information conveyed by phone or written application will be shared with the current member of the board of Your Home Team Cares.Do you agree to the above and that you have filled out the form to the best of your abilities? *YesNoSubmit ApplicationPlease do not fill in this field.