Application for Individual Assistance
Please note: An incomplete application will not be accepted for consideration.
|IMMEDIATE FAMILY INFORMATION|
|CURRENT LIVING ARRANGEMENTS: (Please completely describe arrangements with time-lines, include if you are living with someone, other than mentioned above.)|
|Current Source(s) of Income and Amount:|
|Other support and comments for consideration:|| |
|Financial and Insurance Info|
|Financial Assistance Already Obtained and/or Sought|
|Detailed reason why Assistance is needed:|
|Information on person filling out this application:|
AGREEMENT OF APPLICANT(S):
The Applicant(s) or those acting on behalf of the Applicant(s) agree:
The undersigned authorized the Community Chest of Coral Springs to verify the information provided in this application for assistance. The Community Chest, its Board Members, and/or Representative, will be indemnified and held harmless from any legal liability in vetting this application or providing financial assistance without limitation. The Community Chest will complete review and be mindful of security of such information received in their research/care. Be advised: The Community Chest is subject to audit by government entities.
By submitting this application, you are attesting that all information is true and factual.
|Please provide us with supporting documents: last bank statement, late bill(s), last paystub, lease/rent/mortgage statement.|