PORTLAND REFUGEE SUPPORT GROUP
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PRSG Financial Aid Request
WARNING
:
If you use your smartphone to submit this form we may not receive it. Please use a computer. Thank you!
* If you're not with PRSG please
CONTACT US
.
*
Indicates required field
Today's Date (month/day/year)
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Amount Requested
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What is this aid for?
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Electric Bill
Water Bill
Natural Gas Bill
Garbage Bill
Utility Bill
Phone Bill
Internet Bill
Partial Rent Bill
Full Rent Bill
Other
If Other, please specify in 2 or 3 words (or type N/A)
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Account number of bill (if available) *
*
Due Date
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Please allow 7-14 days for processing.
Client Information
Client Legal Name
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First
Last
Client Cell Phone
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Client Email *
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Client Country of Origin
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Client Date of Arrival in the U.S.
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Client's Alien# or USCIS# (If Available)
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Case Number, if known. (DHS, UN Refugee Case, etc.)
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Client Address
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Line 1
Line 2
City
State
Zip Code
Country
Volunteer
Information
Volunteer Name
*
First
Last
Are you a PRSG volunteer?
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How did you hear about PRSG?
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Email
*
Cell Phone
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WHY CAN'T THE CLIENT AFFORD TO PAY THIS FEE?
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Who works in the household?
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What's the monthly income of each working person in the household?
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How much is the total monthly household income (including benefits)?
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How much money are the monthly household expenses?
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What does the client plan on doing to earn a better income and become self-reliant?
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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?
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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
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Make sure to send us clear pictures (high resolution) of the entire bill/receipt, otherwise we can't help.
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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
".
Submit
Please email bills/receipts ASAP to
syd@pdxrsg.org
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