X-Financial Aid Request (Form A)

PRSG Financial Aid Request (Form A)

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* Indicates required field

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

Amount Requested *

Due Date *

Please allow 7-14 days for processing.

Volunteer Information

Volunteer Name *

First

Last

Email *

Cell Phone *

Client Information

Client Legal Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Cell Phone *

Reason for request:

What is the aid for? *

For 'Other' please specify, or type "N/A" *

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

Have you, as a volunteer, tried finding other aid resources for the client? *

Yes No

If Yes, please list the resources you tried getting aid from, or type "N/A" *

IF NOT, PLEASE CLICK HERE FOR RESOURCES

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 Details

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? *

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

Is there anyone disabled in your household? *

Yes No

Name of disabled person(s) *

Self-Sufficiency Plan

WHAT'S THE CLIENT'S SELF-SUFFICIENCY PLAN? *

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, or leasing 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.), or type "N/A" *

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) *

I will email a copy of the bill(s) ASAP to: yasser@pdxrsg.org

Any Comments? *

** 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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