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 Name

Applicant 2 Last Name

Primary Phone *

Mobile PhoneIf not your Primary Phone

Primary Phone Type

HomeMobile

Primary Email Address *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

List all members of household and ages: *

Finances

Total Monthly Household Income *

USD

Total Monthly Rent/Mortgage *

USD

Utilities (electric) *

USD

Gas (home) *

USD

Cable/Internet/Home Phone *

USD

Groceries *

USD

Mobile Phone(s) *

USD

Car Payment/Rideshare *

USD

Auto Insurance *

USD

Gas (car) *

USD

Medical *

USD

RX *

USD

Other Monthly Expenses not Listed Above

Explain 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? *

USD

List 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 Information

Are you related to any Your Home Team Cares Board Members? *

YesNo

Name of Board Member

References

Please 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? *

YesNo

Reference 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 *

Agreement

Applicant 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? *

YesNo

Please do not fill in this field.