Apply for Assistance Name * First Name Last Name Date of Birth * MM DD YYYY Check One * Single Divorced Legally Separated Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email High school graduate * Yes No College Yes no Certificates and/ or Licenses * Yes No List name of college, degree if any, certificates and/ or licenses. Status Employed Unemployed Student Employer, location, position, weekly pay. If unemployed, how long? If student, school name and when you expect to finish. List all family members who live with you, their ages, and their relationship to you. If 18 or over, provide any source of income. * List all monthly expenses, such as rent, childcare, phone, food, utilites, etc. * Check if you currently receive assistance from: Social Security Temporary Assistance for Needy Families (TANF) Emergency Food Assistance Program (TEFAP) Supplemental Nutrition Assistance Program (SNAP) Women, Infants and Children (WIC) Worker's Compensation Child support Alimony Student work/ study Medicare Medicaid Other If you checked "Other," please describe. Do you have use of a vehicle? * Yes No If "yes," vehicle year, make and model If "no," what is your primary method of transportation? Brief description of the type of assistance you seek from Mom's Love Foundation. * Please tell us what you hope Mom's Love Foundation assistance will change about your current life? I affirm that the information I am submitting is true and correct to the best of my knowledge. I understand if the information I am submitting is determined to be false, the result may be denial of financial assistance, and I may be responsible for and expected to pay for services provided. I also understand that I am voluntarily submitting this application and that I may withdraw it at any time. I also understand that the information contained in my application will remain confidential and will not be disclosed unless legally required or upon my written consent. I further understand that Mom’s Love Foundation does not guarantee that it will provide me with financial assistance, even though I am submitting this application. I agree to be contacted by a representative of Mom’s Love Foundation for the purpose of requesting additional information, and/ or to schedule a video, telephone or in-person interview with me. * Check to affirm Thank you for submitting your assistance application to Mom’s Love Foundation. We will review your application, and contact you very soon.
