Application Portal – Kent Capital

Foundation Giving Application Portal

A. Please tell us about who you are and where you live.

Full Legal Name

Primary Language

Current Place of Residence

Own Home Nursing Facility Adult Family Home Assisted Living Congregate Housing Homeless Hospital Hotel/Motel Residential Care Facility Other

Street Address

City

State

Zip Code

Mailing Address (if different)

City

State

Zip Code

Home Phone

Work Phone

Cell / Message

No Email

I do not have an email address

Is anyone in your family currently receiving assistance?

Yes No

Why do you need our help?

Information Supplier:

B. Please tell us about the people you live with. Start with yourself and list ALL of the people living with you. You do not have to give the Social Security Number or citizenship status of any individual who is not applying for assistance.

Full Legal Name

SSN (last 4 digits)

DOB

Relation to You

U.S. Citizen?

Yes No

Student?

Full Legal Name

SSN (last 4 digits)

DOB

Relation to You

U.S. Citizen?

Yes No

Student?

Full Legal Name

SSN (last 4 digits)

DOB

Relation to You

U.S. Citizen?

Yes No

Student?

Full Legal Name

SSN (last 4 digits)

DOB

Relation to You

U.S. Citizen?

Yes No

Student?

Full Legal Name

SSN (last 4 digits)

DOB

Relation to You

U.S. Citizen?

Yes No

Student?

C. I want to apply for:

TYPES OF ASSISTANCE REQUESTED

Education Grant Tuition Assistance Medical Assistance

D. The following information is collected to be sure that everyone is served fairly without regard to race, color, or national origin. Your answers are voluntary. The information provided will not affect your eligibility or benefit amount. For ethnicity, please select one response. For race, please select all that apply.

Are you Hispanic or Latino?

Yes No

What race are you?

White Asian Black or African American Native Hawaiian or Other Pacific Islander American Indian or Alaskan Native

E. Please tell us about all income for everyone in your home.

Your wages

Frequency

Weekly Bi-Weekly Monthly Other

Wages

Frequency

Weekly Bi-Weekly Monthly Other

Wages

Frequency

Weekly Bi-Weekly Monthly Other

F. Please tell us about all assets for everyone in your home.

Checking / Savings

Other Checking / Savings

Stocks / Bonds / CD's

IRA

You or Your Spouse's Annuity

Other Assets

Trusts

Life Insurance

Vehicle (Year / Model)

G. Your Expenses:

Rent (monthly):

Mortgage (monthly):

Lot Rent / Condo Fee (monthly):

Taxes (yearly):

Dependent Care:

Medical Expenses:

Cost of doing business:

Have you gotten any assistance in the past 12 months?

Yes No

Do you pay for the following utilities separate from your rent or mortgage? (mark all that apply)

Heat Phone Electric Other

H. Please answer all questions.

1. Are you currently employed?

Yes No

2. Have you or anyone in your household received any assistance?

Yes No

3. Are you currently living alone, financially supporting yourself?

Yes No

4. Is anyone in your household blind or disabled?

Yes No

5. Have you sold or transferred property in the last 5 years?

Yes No

6. Is anyone in your household currently receiving assistance from a government program?

Yes No

I. If you want educational, tuition, or medical assistance, please answer all questions in this Section before proceeding to Section J.

1. Is anyone in your household pregnant or has anyone given birth in the last months?

Yes No

2. Do you have any unpaid bills that you would like help paying?

Yes No

3. Do you have documentation to support/prove your financial need?

Yes No

I CERTIFY, UNDER PENALTY OF PERJURY, THAT I HAVE REVIEWED THIS INFORMATION ON THIS APPLICATION, INCLUDING ANY INFORMATION INDICATED ON THE INSERT; IT IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE, INCLUDING THE INFORMATION CONCERNING CITIZENSHIP AND ALIEN STATUS OF THE MEMBERS APPLYING FOR ASSISTANCE. I UNDERSTAND A FULL FINANCIAL AND MEDICAL ELIGIBILITY INTERVIEW MAY NEED TO BE CONDUCTED BEFORE MY ELIGIBILITY CAN BE DETERMINED.

J. Signatures

Applicant Signature

Date

Signature of Person Helping the Applicant

Date

I certify that I have given the above individual(s) the opportunity to review this application. I also certify that I have provided a copy of this form, if one was requested.

Printed Name & Signature

Date

NONDISCRIMINATION STATEMENT

This organization is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex and in some cases religion or political beliefs.

This organization is an equal opportunity provider.

DECLARACIÓN DE NO-DISCRIMINACIÓN

Se prohíbe a esta institución discriminar sobre la base de raza, color, nacionalidad, discapacidad, edad, sexo y, en algunos casos, creencias religiosas o políticas.

Esta institución es un proveedor que ofrece igualdad de oportunidades.