Community Chest Application for Individuals

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Application for Individual Assistance

Please note: An incomplete application will not be accepted for consideration.

APPLICANT'S INFORMATION

Individual Name:
Home Address:
Telephone:
Mobile:
Text:		YesNo
Email:
Email communication preferred:		YesNo
Date of birth:

IMMEDIATE FAMILY INFORMATION

	NAME	RELATIONSHIP	AGE	LIVING WITH YOU - YES OR NO
1.
2.
3.
4.
5.

CURRENT LIVING ARRANGEMENTS: (Please completely describe arrangements with time-lines, include if you are living with someone, other than mentioned above.)

CURRENT COVID ISSUES:

Current Source(s) of Income and Amount:

	Amount	Per
Employment 1
Employment 2
Social Security
Child Support
Family Support
Unemployment
Food Stamps
Disability
Alimony
Church Support
Other income

Other support and comments for consideration:

Employment Record:

Applicant #1

	Company	Position	Years/months worked
1.
2.
3.

Currently Employed?		YesNo
Current Salary

Employment Record

Applicant #2

	Company	Position	Years/Months worked
1.
2.
3.

Currently employed?		YesNo
Current salary

Monthly Expenses

	Amount	Paid to
Rent/Mortgage
Utilities
Cable/Phone/Internet
Insurance -Auto/Life/Health
Car Payment - vehicle 1
Car payment - Vehicle 2
Other monthly bills

Financial and Insurance Info

	Amount	Other info
Cash available
Trust Fund or Securities
Alimony or Settlement

Insurance Coverage		YesNo
Insurance Co. Name
Deductible Amount
Type of insurance:

Financial Assistance Already Obtained and/or Sought

Organization/Person
Contact/Relationship
Amount
Granted		YesNo

Monetary Amount of Financial Assistance Requested:

Detailed reason why Assistance is needed:

Information on person filling out this application:

Name:
Address:
Telephone No.:
Relationship to applicant

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.

Name
Relationship to applicant
Date:

Please provide us with supporting documents: last bank statement, late bill(s), last paystub, lease/rent/mortgage statement.