Request for Assistance Request for Assistance Benevolence - Request for Assistance Request For Assistance Guidelines The goal of the PH4U Hope Chest is to pour hope back into our community by meeting practical financial needs to those seeking assistance. While our desire is to help everyone, we are limited to helping those that are PH4U clients, currently receiving other services. Please note: • It takes at least 2 weeks to process any financial request. • No cash will be given out anytime for any reason. • PH4U will make payment directly to the company to which the payment is owned. • If approved, additional documentation will be required. Name * Name First First Last Last Email * Phone * Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Marital Status SingleMarriedDivorcedSeparatedWidow/Widower Who referred you to PH4U? Personal Information History Have you or anyone in your house recently been arrested and/or convicted of a crime? YesNo If Yes, please briefly describe. Are you currently employed? YesNo If Yes, please provide name of current employer (full and/or part time). How long have you been at your current place of employment? Name of past place of employment (full and/or part time) Past place of employment: Dates of employment Past place of employment: Reason for leaving Have you been assisted by any other church, agency or organization? YesNo If Yes, provide the name of organization as well as the assistance received and date of assistance received. Household Structure Do you live alone? YesNo Please provide the following information on all persons, other than yourself, living in your home with you: Name; Date of Birth; Are they working and/or contributing any money to the household expenses? Person 1 - Full Name * Person 1 - Full Name First First Last Last Person 1 - Date of Birth: Person 1 - Are they working and/or contributing any money to the household expenses? * YesNo Person 2 - Full Name Person 2 - Full Name First First Last Last Person 2 - Date of Birth Person 2 - Are they working and/or contributing any money to the household expenses? YesNo Person 3 - Full Name Person 3 - Full Name First First Last Last Person 3 - Date of Birth Person 3 - Are they working and/or contributing any money to the household expenses? YesNo Your Situation Your Situation Please describe the situation that has caused you to ask for assistance at this time. * * What is your need today? * Pay utility billsPay rent, mortgageCar repairs If you have more than one need; from the list to your right please, by priority, list your type of need. * (EX: My needs in priority list - 1. Rent 2. Utilities) * Documentation required before consideration. *Budget Sheet *A copy of the full bill that you are requesting assistance with and/or other documentation *A copy of your photo ID *If you are needing assistance with rent or mortgage; please upload a copy of your complete lease agreement or mortgage statement. *I understand I will have to provide correct and full documentation before I can be considered for assistance from Pregnancy Help 4 U. * * *I understand I will have to provide correct and full documentation before I can be considered for assistance from Pregnancy Help 4 U. * First First Last Last Upload your Budget Sheet here: * Drop a file here or click to upload Choose File Maximum file size: 268.44MB Upload a copy of your full bill here: * Drop a file here or click to upload Choose File Maximum file size: 268.44MB Upload a copy of your photo ID: * Drop a file here or click to upload Choose File Maximum file size: 268.44MB Upload a copy of any other complete bill you are needing assistance with. This can include your lease agreement, mortgage statement, car repairs, utilities: Drop a file here or click to upload Choose File Maximum file size: 268.44MB *I hereby authorize the release of information to Pregnancy Help 4 U (PH4U) to receive the assistance I am requesting. I further certify the information I have stated is true and correct and that all income is reported. I understand PH4U may verify the information on this application and that deliberate misrepresentation of information may subject me to denial of assistance/services. * *I hereby authorize the release of information to Pregnancy Help 4 U (PH4U) to receive the assistance I am requesting. I further certify the information I have stated is true and correct and that all income is reported. I understand PH4U may verify the information on this application and that deliberate misrepresentation of information may subject me to denial of assistance/services. First First Last Last *I give permission for PH4U to discuss my case with other agencies, businesses, churches, attorneys, individuals, and any other deemed necessary to verify application information and/or identify additional sources of assistance. I understand that all information will remain as private as possible within these entities. * *I give permission for PH4U to discuss my case with other agencies, businesses, churches, attorneys, individuals, and any other deemed necessary to verify application information and/or identify additional sources of assistance. I understand that all information will remain as private as possible within these entities. First First Last Last *I understand that the assistance I am applying for may not be approved. * *I understand that the assistance I am applying for may not be approved. First First Last Last *I have read, understood, and agree to the policies above regarding the Release Of Information. * *I have read, understood, and agree to the policies above regarding the Release Of Information. First First Last Last Please enter your first/last name for each statement above as an acknowledgment that you have read and understand each statement. Date Signed * If you are human, leave this field blank. Submit
