Application for Financial Assistance

Application for Financial Assistance
Personal Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Email
example@example.com
Please list all people who reside in your household:
Please explain any assistance you are requesting:
What amount of assistance are you requesting?
Please briefly explain the circumstances which brought about this need:
Please describe how your financial situation has changed since the financial crisis or medical diagnosis.
From what other sources have you requested financial assistance in the last year? Please include all organizations for which you have applied or received assistance and indicate the amount provided below.
Please indicate any type of financial aid you may be receiving from a government agency.

Unemployment InsuranceSocial SecurityWorker's CompensationDisability InsuranceSupplemental Nutrition Assistance Program (SNAP)Other
How did you hear about Nothing Is Impossible Foundation?
Please attach any pertinent medical and/or financial documentation related to your request. For example, if this request applies to a need related to a medical condition, please include a statement of diagnosis from your physician. NIF may also request documentation related to your income.
Browse Files

Cancelof
Are you willing to consider financial counseling if it was offered to you?

YesNo
Print Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Please enter income/payment amounts under Monthly Income/Payment Field.
Do you receive food stamps or use food pantries?

YesNo
Do you receive any assistance for rent, utilities, child care?

YesNo
If yes, how much do you receive on a monthly basis? (Please do not include in total above table)
Should be Empty:

Application for Financial Assistance

Personal Information