SVdP at Saint Marguerite d’Youville Catholic Church – Financial Assistance Request English

Assistance Request Form

Please select the zip code where you live:*

If you do not reside in 30044 and are not a registered St. Marguerite d'Youville parishioner, you will not be eligible for assistance through the St. Marguerite d'Youville St. Vincent de Paul Conference. Please call the main St. Vincent de Paul Georgia assistance line at 678-892-6163 to be connected with a local Conference that may be able to assist you.

Date

Head of Household Information

Name*

First Middle Last Maiden

SSN

Last 5 digits

Date of Birth*

Gender*

Race*

American Indian/Alaskan Native
Asian
Black
Caucasian
Hispanic/Latino
Native Hawaiian/Pacific Islander
Unknown

Email*

Address*

Street Address Address Line 2 City State ZIP Code

How long at this address?

Apartment Complex Name

If applicable

Primary Phone*

Work Phone

Other Phone

Marital Status*

Employment History Information

Are you employed?*

Yes
No

Date of Unemployment*

Briefly, please explain why you are not employed:

Employer or Most Recent Employer

Full-time
Part-time

How long employed:*

Other Information

Church Affiliation (If any)

This does not affect your application status.

Household Make-Up

How many children are in household?*

How many adults are in household?*

Total # of People In Household*

Please list first and last name, date of birth and gender for each additional member in your household. (Do not include dependenet children here. You can enter their information later.)

Child 1

Name

First Last

Date of Birth

Gender

Children's Information

Child 1

First Last

Date of Birth

Gender

Child 2

First Last

Date of Birth

Gender

Children's Information

Child 1

First Last

Date of Birth

Gender

Child 2

First Last

Date of Birth

Gender

Child 3

First Last

Date of Birth

Gender

Children's Information

Child 1

First Last

Date of Birth

Gender

Child 2

First Last

Date of Birth

Gender

Child 3

First Last

Date of Birth

Gender

Child 4

First Last

Date of Birth

Gender

Children's Information

Child 1

First Last

Date of Birth

Gender

Child 2

First Last

Date of Birth

Gender

Child 3

First Last

Date of Birth

Gender

Child 4

First Last

Date of Birth

Gender

Child 5

First Last

Date of Birth

Gender

Children's Information

Child 1

First Last

Date of Birth

Gender

Child 2

First Last

Date of Birth

Gender

Child 3

First Last

Date of Birth

Gender

Child 4

First Last

Date of Birth

Gender

Child 5

First Last

Date of Birth

Gender

Child 6

First Last

Date of Birth

Gender

If you have more than 6 children living in your household, please finish listing out the rest of the names below:

Spouse / Other Adult In Household (if applicable)

Name

First Middle Last

SSN

Last 5 Digits

Date of Birth

Gender

Race

American Indian/Alaskan Native
Asian
African American
Caucasian
Hispanic/Latino
Native Hawaiian/Pacific Islander
Unknown

Purpose of Request & Amount

Have you been helped by St. Vincent de Paul Georgia before?*

Yes
No

Date of last assistance from St. Vincent de Paul Georgia*

Current Assistance Request Type

Please tell us about your situation and the amount you are requesting*

Include the circumstances that led you to this situation and other details pertaining to your need for assistance.

Please visit this website if you need help to apply for Food Stamps:

www.svdpgeorgia.org/snap-referral

COVID-19 Impact

Has Covid-19 impacted your situation?*

Yes
No

How has Covid-19 impacted your situation?*

Please select reason below:

Loss of employment (Layoff/furlough)
Loss of wages or loss of working hours
Positive COVID-19 test
Loss of wages due to lack of childcare
Loss of wages/employment due to being of a COVID-19 high-risk population
Loss of employment due to children at home - virtual learning

Please upload documentation of Covid-19 impact:

Example: Loss of employment/termination letter, unemployment statement, positive Covid-19 test results, paystubs to show loss of wages, etc. *All documentation must have applicant's name on it. (jpg, gif, png, pdf files accepted). If you cannot upload this now, you may be asked to provide it to your caseworker once assigned.

Drop files here or

Max. file size: 50 MB.

Finances

Are you currently receiving the following benefits?

Medicare*

Yes
No

Medicaid*

Yes
No

SNAP (Food Stamps)*

Yes
No

WIC*

Yes
No

Veteran*

Yes
No

Income (monthly)

Please enter the amount you receive for each.

Alimony

Child Support

Your Employment

Spouse/Roommate Employment

Food Stamps

Retirement/Pension

Social Security

SSI, SSD

TANF (AFDC)

Unemployment

Veteran Benefits

Workers' Compensation

Other

Total Income

Expenses (monthly)

Please enter the amounts you need to pay.

Alimony

Child Support

Child Care

Food

Electricity

Water/Sewer

Natural Gas/Propane/Heating Oil

Telephone

Rent/Mortgage

Prescriptions/Medical

Transportation/Car Payments

Insurance (Auto, Health, Dental, Life)

Loans/Credit Card

Cable/Satellite/Internet

Other

Total Expenses

Please list any bills you would like us to consider to pay:

Please upload documentation of current bills you are requesting to be paid:

(Late/eviction Notice, Mortgage Notice, Late Utility Bill) *All documentation must have applicant's name on it. (jpg, gif, png, pdf files accepted). If you cannot upload this now, you may be asked to provide it to your caseworker once assigned.

Drop files here or

Max. file size: 50 MB.

Please upload proof of residency:

(copy of a utility bill, signed lease copy, etc. that shows you are a resident of 30044 zipcode) *The document should have your name and address on it. (jpg, gif, png, pdf files accepted). If you cannot upload this now, you may be asked to provide it to your caseworker once assigned.

Max. file size: 50 MB.

Agencies applied to within the last 12 months (Please give info on all that apply):

Name of Agency

Purpose of Request

Amount Given

Date

Name of Agency

Purpose of Request

Amount Given

Date

CARES Act Funding Grants

I confirm that to the best of my knowledge, I have not received any funds/grants from another non-profit agency that is associated with COVID-19 Relief Assistance .*

I agree
I disagree
I'm not sure

Authorization For Release of Confidential Information:

I accept

In consideration of the services to be undertaken or rendered on my behalf by the Society of St. Vincent de Paul, its members, agents or affiliated organizations (hereinafter referred to as "SVdP", I, the undersigned hereby authorize SVdP to receive, from any and all sources, and to release to any person or organization, any confidential information regarding me which may be necessary or useful to SVdP in relation to the services to be rendered.

I hereby release SVdP from all liability in any way related to the receipt and/or release of said confidential information. I further understand that the release of this information does not guarantee that assistance will be provided. but that without such information my case cannot be considered. This release expires sixty (60) days after the Undersigned signature date.

Signature*

Comments

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

SVdP at Saint Marguerite d’Youville Catholic Church – Financial Assistance Request English

Assistance Request Form

Head of Household Information

Employment History Information

Other Information

Household Make-Up

Child 1

Children's Information

Children's Information

Children's Information

Children's Information

Children's Information

Spouse / Other Adult In Household (if applicable)

Purpose of Request & Amount

Please visit this website if you need help to apply for Food Stamps:

COVID-19 Impact

Finances

Income (monthly)

Expenses (monthly)

Agencies applied to within the last 12 months (Please give info on all that apply):

CARES Act Funding Grants

Authorization For Release of Confidential Information:

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