Emergency Financial Assistance

One-time financial disruption Application

> READ THIS DOCUMENT BEFORE COMPLETING THE APPLICATION PROCESS

I have read the document outlining information on eligibility, qualifying expense, application process and required documentation to apply.*
I meet the requirements to submit an application
Please note: You cannot save your application and return at a later time to complete the submission. All required fields and documents must be submitted in one sitting. All required fields must be completed, including uploaded documentation, or your application will be not be considered.
Applicant's Name*
First Last
Are you a current client or participant of JFCS?*
- Yes
- No
If so, who is the staff person you work with regularly?

Please note: If you or a member of your household is currently a JFCS client or participant and in need of financial assistance, reach out to the JFCS staff person you work with regularly.
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address City State ZIP Code
Phone*
Email*
Household Members’ Name(s) and Birthdate(s)*
(First name, Last Name, Date of birth)
What is your faith or religion?*
Note: Your response does not affect eligibility for financial assistance.
How did you hear about JFCS?*
How will the financial assistance you are requesting be used?*
- Auto repair
- Appliance repair
- Moving company expense
What amount of financial assistance are you requesting?*
Please describe the event that has disrupted your finances.*
Please report all income and expenses for your household. For income/expenses with fluctuating amounts from month to month, please provide your best estimate on an average monthly amount.
MONTHLY INCOME
Please use $0 for blank responses.
Applicant's monthly salary*
Monthly salary from others*
Any Income from Social Security*
(how much Social security, SSI, or SSDI are you receiving a month?)
Pension*
Rental/Business Income*
Interest/Dividend Payments*
Unemployment*
SNAP/Food Support*
MFIP/GA*
Child Support*
Spousal Support*
Financial Support from Others*
Other Income*
MONTHLY EXPENSES FOR THE HOUSEHOLD
Please use $0 for blank responses.
Rent/Mortgage*
Rent/Home Insurance*
Electric/Gas*
Phone/TV/Internet*
Food/Cleaning supplies/Paper products*
Car Payment*
Car Insurance*
Car Maintenance/Gas*
Bus/Taxi/Shared Ride Service*
Medical Insurance*
Health-related Supplies*
House Maintenance*
Personal needs/Clothing/Toiletries*
In-home Services*
Child Care*
Tuition/Education*
Credit Card Payment*
Pet Care*
Other regular debt or payments*
Required Documentation must be uploaded below.
Files accepted include PDF, JPG, PNG, DOCX
Estimate for qualifying expense*
Accepted file types: pdf, jpg, png, docx, Max. file size: 50 MB.
Proof of current auto insurance
(for auto repair requests only)
Accepted file types: pdf, jpg, png, docx, Max. file size: 50 MB.
Proof of valid driver’s license
(for auto repair requests only)
Accepted file types: pdf, jpg, png, docx, Max. file size: 50 MB.
I certify the information provided is complete and accurate to my knowledge. I understand JFCS considers one application per household at a time and available funding is capped. Therefore, if another member of my household applies, JFCS may disclose the status and/or determination of this application as it relates to applicants’ eligibility and grant limits. I understand there is no guarantee all applications can be approved.*
I agree
Please type your name as an electronic signature of this form*
Date*
MM slash DD slash YYYY

One-time financial disruption Application

Please note: You cannot save your application and return at a later time to complete the submission. All required fields and documents must be submitted in one sitting. All required fields must be completed, including uploaded documentation, or your application will be not be considered.

Please report all income and expenses for your household. For income/expenses with fluctuating amounts from month to month, please provide your best estimate on an average monthly amount.

MONTHLY INCOME

MONTHLY EXPENSES FOR THE HOUSEHOLD

Required Documentation must be uploaded below.