Financial Aid Request

* Indicates required field

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

Type of Aid Needed *

One-Time Aid Long-Term Aid (2 months or more)

Amount Requesting *

When is the amount due? (Date) *

Please allow 7-10 days for processing.

As you know, you are supposed to exhaust all resources before requesting financial aid from PRSG. Please list all resources you've tried to get aid from (see Resources page on website) *

Click HERE for RESOURCES

Volunteer Information

Volunteer's Name *

First

Last

Email *

Cell Phone *

Client Information

Client's Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Cell Phone *

Reason for request:

Reason for request, in 2-3 words *

What has changed in the client's situation to need this aid now? *

Name and address of service provider:

Please type the name and address of the service provider which will be receiving the money. Note that if this request is approved, all monies will be paid directly to the service provider. *

Client Assessment

Please type "N/A" if a question does not apply to the client.

Does anyone in the household work? *

Yes No

Names of people who work *

How many hours of work per week for the household? *

Are you looking for work? *

Yes No

If your household does not have work income, please explain why? *

If you've contacted IRCO to help you find a job, when was that (date)? *

Is there anyone disabled in your household? *

Yes No

If Yes, does this person(s) receive disability? *

Yes No

Name of disabled person(s) *

What plan do you have to achieve self-sufficiency? *

Have you received the stimulus check from the government? *

Yes No

If Yes, how much did you receive? *

How much of it is left? *

How was it spent? *

Monthly Expenses & Income

Please type "0" if the amount is $0.

EXPENSES *

Electric *

Natural Gas (for home) *

Water *

Housing Rent/Mortgage *

Garbage *

Phone Expenses *

Do you own a car? *

Yes No

Car Payment *

Car Insurance *

Gas for car *

Other Transportation (transit, etc) *

Food *

Other Expenses on a monthly basis *

Please explain what these other expenses are in detail (cigarettes, clothing, household supplies, etc.) *

Total Expense *

INCOME *

TANF (Cash Assistance) *

Food Stamps (SNAP) *

Housing Assistance *

Unemployment *

SSI (disability) *

Work Income *

Other Income - Please explain in detail *

Total Income *

Expense - Income = (Please subtract) *

Required Documents

Expenses:
1. Home lease
2. Current utility bills
3. Current proof of car payment plan (if applicable)

Income:
1. Last 2 pay stubs from each working person
2. SSI
3. TANF
4. Food Stamps
5. 2019 Tax Return
6. Last 2 bank statements until today's date

Note that the client's case will not be considered without these documents.

I will email copies of these documents ASAP to: yasser@pdxrsg.org

** By submitting this form, you are attesting that all information provided is true and correct to the best of your knowledge and that you are giving PRSG permission to speak to the service provider on your behalf in the event more information is needed. To apply you must be a current or prior PRSG client. For questions, please email us at: info@pdxrsg.org

*** PRSG reserves the right to deny assistance to any client based on misleading, false or insufficient information, or lack of funds. PRSG may contact a client or core volunteer at any time for further information if needed. PRSG does not discriminate on the basis of race, creed, color, ethnicity, national origin, religion, gender, orientation, age, height, weight, physical or mental ability, veteran status, military obligations, or marital status.

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