Have you recently or are you experiencing a catastrophic loss? (Natural disaster, fire, death, violent crime, medical life threatening emergency)? *

Yes

No

Do you have access to saving or funds from any of the following accounts? Checking, saving, 401K, IRA, 403b, any retirement accounts? *

Yes

No

Have you leveraged all your current assets? Second mortgage, credit cards, life insurance policies, annuities? *

Yes

No

Do you have relatives in the area that can assist you? *

Yes

No

Have you contacted any relatives for help? *

Yes

No

Name *

First Name

Last Name

Date *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Have we helped you before? *

Yes

No

Are you employed? *

Yes

No

Are you receiving government aid? (unemployment, Social Security, food stamps, worker's compensation? *

Yes

No

Checkbox *

Request for financial assistance requires the individual/family to bring in the following items for review: - Review three months of your payroll. - Review checking account expenditures in the last two months. -Review credit card expenditures for the last two months. -Review weekly/monthly bills. (mortgage/rent, cars, cable, phone, utilities, debt payments, etc.) -Review retirement accounts. (IRA accounts, savings accounts, 401K, 403b, etc. This includes the spouse's retirement accounts as well).

By checking this box I understand the information above, responses are accurate to my knowledge, and agree to the terms described.