Apply for Assistance

If you are experiencing a temporary financial hardship, we're here to listen. Please complete the application below with as much detail as possible so we can better understand your situation and determine how we may be able to assist. Every request is reviewed with compassion, respect, and confidentiality.

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Name *

First

Last

Date of Birth *

MM/DD/YYYY

Email *

Email

Confirm Email

Phone # *

Address *

Street address, city, state and zip code

How many adults live in your household? *

How many children (under 18) live in your household? *

Please list the names and ages of everyone living in your household. *

Employment Information *

• Full-Time
• Part-Time
• Self-Employed
• Unemployed
• Disabled
• Retired
• Student

Monthly Household Income (Approximate): *

Assistance Requested *

• Rent/Mortgage
• Utilities
• Transportation/Vehicle
• Food
• Emergency Financial Assistance
• Funeral
• Other

What type of assistance are you requesting? (Check all that apply.)

Amount Requested: *

Please describe the circumstances that led to your financial hardship. *

describe in Income

Applicant Certification (Type in your Name) *

I certify that the information provided in this application is true and accurate to the best of my knowledge. I understand that submitting an application does not guarantee assistance. Uprising Foundation reserves the right to request additional information to verify my circumstances.

Submit