Emergency Assistance Application | Affordable Housing US

Emergency Financial Assistance Application

Date*

Name*

First Last

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Preferred Method of Contact:*

Select All
Phone
Text
Email

Total number of people living in your household:*

List household members (Name / Age / Relationship):

Are there any children or dependents under your care?*

Yes
No

If yes, please describe:

Current Employment Status:

Full-time
Part-time
Unemployed
Self-employed
Retired
Other: ______

Employer Name:

Monthly Gross Income:

Other sources of income (benefits, child support, etc.) :

Total Monthly Household Income:*

Type of assistance requested:*

Select All
Rent/Housing
Utilities
Vehicle Repair
Gas/Transportation
Food
Medical
Other:

Total Amount Requested:*

Who should payment be made to (if approved)?

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Account Number:*

1. Please describe your current financial situation and what led you to need assistance:*

2. What has recently changed in your life or circumstances that caused this hardship?*

3. Have you received financial assistance from any other organization in the past 12 months?

Yes/No?*

Yes
No

If yes, list details:

5. How do you plan to get back on your feet financially?*

6. If we’re unable to cover the full amount requested, what minimum assistance would still help you most?*

Please attach copies of:*

Select All
Recent pay stubs or proof of income
Bill, invoice, or repair estimate related to your request
Any other documents that support your situation

(These questions help us better understand your circumstances. Please answer any that apply.)

1. How soon do you need this assistance?*

Within 24 hours
Within 3 days
Within a week
Within a month

2. What will happen if assistance is not received soon? (Examples: eviction, shutoff, loss of transportation, etc.)*

3. Have you received any official notice (cut-off, eviction, repossession, etc.)?*

Yes
No

If yes, describe:

4. Which monthly expenses are most difficult to keep up with right now? (List up to three):

5. Do you currently have a written budget or spending plan?*

Yes
No

If yes, what adjustments have you made recently?

6. Have you reached out to any family, friends, church, or community organizations for help?*

Yes
No

If yes, how have they supported you?

7. Have you received financial assistance from our organization before?*

Yes
No

If yes, when and for what purpose?

8. What would financial stability look like for you in the next 3–6 months?

9. If available, what type of non-financial support would help you most right now?*

Budgeting Help
Job or housing resources
Prayer or emotional support
Other: _____

11. Is there anything else you’d like us to understand before reviewing your application?

I certify that the information provided is true and complete to the best of my knowledge. I understand that submitting this application does not guarantee assistance and that funds are based on availability and need. Type name below as a signature.

Name*

First Last

Date*

Email

This field is for validation purposes and should be left unchanged.