HSLC Caring Fund Application

Information on this application is kept confidential.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

How did you hear about HSLC?

STATEMENT of NEED

Food

Housing

Utilities

Medical

Transportation

Other

Amount of financial assistance requested:

Note: our funds are for short-term needs under $300; for larger needs, we encourage you to work with Hopelink or other housing agencies.

What circumstances have created your need?

DETAILS of NEED

Have you received assistance from Holy Spirit before?

Yes

Unsure

If YES, please indicate dates and amounts received:

If this request is for $200 or more, please answer the following 3 questions:

SUMMARY of FINANCIAL NEED

What type of assistance do you currently receive and what options are available to you for support/assistance?

What other information would you like to communicate to Holy Spirit Lutheran Church for consideration?

STATEMENT of ACCURACY

I hereby affirm that all the above stated information provided by me is true and correct to the best of my knowledge.

Type your name here

Date

YYYY