Financial Assistance Application

Applicant Name*

First Last

Email*

Enter Email Confirm Email

Address*

Street Address Address Line 2 City 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.

Amount

Utility: (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.

Amount

A 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

Relationship

Age

Name

First Last

Relationship

Age

Name

First Last

Relationship

Age

Name

First Last

Relationship

Age

Employment

Are you employed?*

Yes

No

Do you receive any other income including but not limited to child support, AFDC, Disability, Social Security, or other benefits?*

Yes

No

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 Plan

What 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.

By filling out and signing this document, you agree to the terms listed above to receive financial assistance through Girl Talk Inc.

Name

This field is for validation purposes and should be left unchanged.

Financial Assistance Application

What assistance are you requesting?

HOUSEHOLD COMPOSITION

Financial Plan

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