Financial Assistance Application "*" indicates required fields Step 1 of 4 25% Applicant Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home or Mobile Phone* What assistance are you requesting?Rent: (rent assistance cannot exceed $1000 and recipient must be in eviction status) Successful applicants approved to receive assistance through Girl Talk Inc. will provide applicants with two-time rental assistance within a 12-month calendar period starting on the date of application approval. If an applicant is in need of the second assistance, it will be made 6 months after the first disbursement, with a prior required completion of EmPower Her Support program. Payment will not exceed $1,000 to individuals showing supporting documents they are behind on their rent or have been issued an eviction notice. AmountUtility: (one choice of utility must be a current bill in Disconnect Status Only) Successful applicants approved to receive assistance through Girl Talk Inc. will provide applicants with two-time assistance within a 12-month calendar period starting on the date of application approval. Choice of one Utility bill that is a current bill, in disconnect status. If applicant is seeking the second assistance, it will be made 6 months after the first disbursement, with a prior required completion of EmPower Her Support Program. Utility bill must be in disconnect status.AmountA prerequisite to receive financial support the second time through Girl Talk Inc, is required that you must attend the EmPower Her Support Program. This is a program that provides not only financial assistance, but social and emotional support along with mental health and wellness programs.Are you willing to attend financial counseling and other related programs?* Yes No (Please be advised that financial counseling / Budgeting is a requirement to receive assistance again through the Girl Talk, Inc. Program.) HOUSEHOLD COMPOSITION(List all other members living in the home. Give the relationship of each family member to the head.) Name First Last RelationshipAgeName First Last RelationshipAgeName First Last RelationshipAgeName First Last RelationshipAgeEmploymentAre you employed?* Yes No If yes, where do you work?*If unemployed, please give a detailed explanation as to why you are not employed.*Do you receive any other income including but not limited to child support, AFDC, Disability, Social Security, or other benefits?* Yes No If yes, please state:*Reason for Assistance: Explain briefly why you are seeking financial assistance from Girl Talk, Inc. Include any relevant details about your current financial situation, unexpected expenses, or other challenges that have affected your ability to pay rent and utilities.* Financial PlanWhat are your plans to improve your current financial situation? Give a brief description of your financial goals and a plan of action.*To complete your application, the following is required: • Lease (With your name on it) that can verify your finicial need • Drivers Licenses for you and all adults in the home (Front and back) • Proof of Income documentation (Two most recent check stubs and employment will be verified), benefit letters from WIC, TANF, SNAP, HIP, SSI, EAP etc. • Utility bill (In disconnect notice status) • If staying in a hotel, please submit receipts of payment to be verified All documents must be received within 24 hours of acknowledgment of assistance request.Consent By checking this box, you acknowledge that Girl Talk Inc reserves the right to decline any request due to the submission of fraudulent information and the inability to verify all documents submitted.By filling out and signing this document, you agree to the terms listed above to receive financial assistance through Girl Talk Inc.PhoneThis field is for validation purposes and should be left unchanged.
