Financial Aid Request

PORTLAND REFUGEE SUPPORT GROUP

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Financial Aid Request

WARNING: If you use your smartphone to submit this form we may not receive it. Please use a computer. Thank you!

* This form is FOR PRSG VOLUNTEER USE ONLY. If you're not with PRSG please CONTACT US.

* Indicates required field

Today's Date (month/day/year) *

Amount Requested *

Is this request related to COVID? *

Yes No

What is this aid for? *

Water Bill Electric Bill Natural Gas Bill Phone Bill Partial Rent Bill Full Rent Bill Other

If Other, please specify in 2 or 3 words (or type N/A) *

Due Date *

Please allow 7-14 days for processing.

Client Information

Client Legal Name *

First

Last

Is this person a PRSG client? *

Client Cell Phone *

Client Country of Origin *

Client Date of Arrival in the U.S. *

Client's Alien# or USCIS# (If Available) *

Client Address *

Line 1

Line 2

City

State

Zip Code

Country

Volunteer Information

Volunteer Name *

First

Last

Are you a PRSG volunteer? *

Email *

Cell Phone *

WHY CAN'T THE CLIENT AFFORD TO PAY THIS FEE? *

Does the client or anyone in the household have a job? *

- If YES, what is the total monthly salary of all working people? *

What is the total monthly household income (including benefits)? *

What are the monthly household expenses? *

What does the client plan on doing to earn a better income and become self-reliant? *

As you know, volunteers are required to look for resources to help the client's financial needs before asking PRSG for aid. Have you, as a volunteer, tried finding other aid resources for the client? *

Yes No

IF NOT, PLEASE CLICK HERE FOR RESOURCES, and don't forget to search the internet as well!

If 'YES' but unsuccessful, please list the resources you've contacted for help. *

Any Comments? *

I will email a picture of the bills / receipts ASAP to: yasser@pdxrsg.org

Please allow 7-14 days for processing.

∙ Make sure you click the SUBMIT button well, until you see the confirmation message "Thank you. Your information has been submitted" or you see the message "Please correct the highlighted fields".

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