PORTLAND REFUGEE SUPPORT GROUP
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PRSG Financial Aid Request (Form B)
WARNING
:
If you use your smartphone to submit this form we may not receive it. Please use a computer. Thank you!
*
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?
*
Partial Rent Bill
Full Rent Bill
Other
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
*
Expense Amount
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
*
Income Amount
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
Bills:
1. All bills related to the aid request
Expenses:
1. Home lease/mortgage
2. Current utility bills
3. Current proof of car payment plan
(if client is leasing a car)
Income:
1. Last 2 pay stubs from each working person
(if applicable)
2. SSI
(if applicable)
3. TANF
(if applicable)
4. Food Stamps
(if applicable)
5. 2019 Tax Return
6.
Last 2
bank statements until today's date
*
I will email copies of these documents and any related bills ASAP to: yasser@pdxrsg.org
Note that the we cannot considered the client's case without these documents. If you have any issues providing documents, please email yasser@pdxrsg.org. Thank you!
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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