Application For Assistance Get InvolvedDonate APPLICATION FOR ASSISTANCE REQUESTED DETAILSCash Amount or Items Requested?(Required)Purpose of Request?(Required)What events lead to your needing assistance?(Required)Have you received assistance from us in the past?(Required) Yes NoIf yes, When/What for?(Required)What steps have you taken to improve your situation?(Required)Have you seen a financial counselor within the last six months?(Required) No YesIf yes, with whom?(Required)PERSONAL INFORMATIONFirst Name:(Required)Last Name:(Required)Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address:(Required) Cell Phone:(Required)Work Phone:Home Phone:Gender:(Required) Female MaleDate of Birth:(Required) Month Day YearAge:(Required)Marital Status:(Required)SingleMarriedEngagedDivorcedWidowedSeparatedLOCATION AND LIST EVERYONE CURRENTLY LIVING IN YOUR HOMEAddress of Residence:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you Own/Purchasing or Renting?(Required) Own/Puchasing RentingHow long at present residence (Years)?(Required)Do you have access to a car?(Required) Yes NoHow many people are living in the home?(Required)Please list everyone living in the home:1st Person(Required)Name:Age:Relationship:2nd Person(Required)Name:Age:Relationship:3rd Person(Required)Name:Age:Relationship:4th Person(Required)Name:Age:Relationship:5th Person(Required)Name:Age:Relationship:6th Person(Required)Name:Age:Relationship:7th Person(Required)Name:Age:Relationship:8th Person(Required)Name:Age:Relationship:9th Person(Required)Name:Age:Relationship:10th Person(Required)Name:Age:Relationship:PRIMARY APPLICANT EMPLOYMENT HISTORYPrimary Applicant Name:(Required) First LastPresent/Most Recent Employer:(Required)How long were you emplyed? (Years)(Required)Currently Working?(Required) Yes NoSupervisor:(Required)Employer Phone:(Required)Employers Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Position and Job Description:(Required)Are you seeking employment?(Required) Yes NoWhere are you currently seeking employment?(Required)How long have you been unemployed? (Months)(Required)What steps are you taking to seek active employment?(Required)Reason for leaving last employer:(Required)SPOUSE EMPLOYMENT HISTORYSpouse Name:(Required) First LastSpouses Present/Most Recent Employer:(Required)How long is/was the spouse emplyed? (Years)(Required)Spouse Currently Working?(Required) Yes NoSpouses Supervisor:(Required)Spouses Employer Phone:(Required)Spouses Employer Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Spouses Position and Job Description:(Required)Spouse seeking employment?(Required) Yes NoWhere's the spouse currently seeking employment?(Required)How long has the spouse been unemployed? (Months)(Required)What steps is the spouse taking to seek active employment?(Required)Reason for the spouse leaving last employer:(Required)AUTHORIZATION(Required) I certify that the statements made above are true and complete to the best of my knowledgeBy submitting this form, I certify that the statements made above are true and complete to the best of my knowledge. I give permission to POG to make inquiries as needed to determine if they are able to assist me. Offers of assistance will be based on the validity of my request, available resources and my active participation in the improvement of my financial health and well-being.PhoneThis field is for validation purposes and should be left unchanged.
