Financial Aid Request

* Indicates required field

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

Amount Requested *

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

Account number of bill (if available) * *

Due Date *

Please allow 7-14 days for processing.

Client Information

Client Legal Name *

First

Last

Client Cell Phone *

Client Email * *

Client Country of Origin *

Client Date of Arrival in the U.S. *

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

Case Number, if known. (DHS, UN Refugee Case, etc.) *

Client Address *

Line 1

Line 2

City

State

Zip Code

Country

Volunteer Information

Volunteer Name *

First

Last

Are you a PRSG volunteer? *

How did you hear about PRSG? *

Email *

Cell Phone *

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

Who works in the household? *

What's the monthly income of each working person in the household? *

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

How much money 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. *

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

Make sure to send us clear pictures (high resolution) of the entire bill/receipt, otherwise we can't help.

If the service provider has an online payment system, make sure the client sets up their online account so we can pay the bill quicker.

Any Comments? *

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".

PRSG Financial Aid Request

Client Information

Volunteer Information