Form of Need Application - Outer Banks Relief Foundation

Date of Application*

CANDIDATE'S PERSONAL INFORMATION

Candidate’s Name*

First Last

Candidate’s Date of Birth*

Gender

Candidate’s Physical Street Address*

Street Address City State ZIP Code

Mailing Address (if different from above)

Street Address City State ZIP Code

Candidate’s Telephone Number*

Other Number

Candidate’s Email Address*

How Long Have You Lived at Your Current Address?*

Race/Ethnicity

FAMILY STATUS

Marital Status*

Are there any other persons living with you?*

Yes

Do you have children?*

Yes

Do you have pets in the home?*

Yes

Provide the name, age and relationship of each person/child (click + to add more)*

Name

Age

Relationship (son, daughter, parent, etc.)

How did you hear about the Outer Banks Relief Foundation, Inc.?

Have you ever received assistance from the Outer Banks Relief Foundation before?*

Yes

Have your contacted InterFaith Community Outreach?*

Yes

Have your contacted Dare County Social Services?*

Yes

OBRF CANDIDATE'S CIRCUMSTANCE / STATEMENT OF NEED

Describe Candidate’s Circumstance / Statement of Need*

Dollar amount requested for OBRF candidate*

For which bills?*

What efforts have you undertaken to address or help resolve your situation/circumstances? (Please explain)*

Have you applied for unemployment? If not, why not?

How do you see your financial situation in the next 90 days? (Please explain)*

In order for us to measure the full amount of unmet need of our applicants, please indicate the entire amount that would resolve your crisis, even if that amount seems unrealistic to ask for.*

HOUSEHOLD INCOME INFORMATION (Include ALL)

Total Monthly Income*

Present or Previous Employer*

Weekly*

Monthly

Employer Address*

Street Address City State ZIP Code

Type of Work (Please Indicate)

Supervisor Name

Employment Type (Select One)

Full Time

Part Time

Temporary

Seasonal

Other Household Member Employer

Weekly

Monthly

Type of Work (Please Indicate)

Supervisor Name

OTHER INCOME / BENEFITS

Child Support*

$ Amount Received

Date Began

Date Ends or Ended

Workman’s Compensation Benefits*

$ Amount Received

Date Began

Date Ends or Ended

Disability/SSI Benefits*

$ Amount Received

Date Began

Date Ends or Ended

Unemployment Benefits*

$ Amount Received

Date Began

Date Ends or Ended

Other Income*

$ Amount Received

Date Began

Date Ends or Ended

Value of Assets (home, retirement, savings)*

Do you have Health Insurance Benefits?*

Yes

Coverage Date*

Provide Coverage Details*

HOUSEHOLD EXPENSE INFORMATION

Total Monthly Expenses*

Mortgage/Rent*

$ Monthly Amount

$ Amount Currently Due

Car/Transportation*

$ Monthly Amount

$ Amount Currently Due

Electric/Gas/Water*

$ Monthly Amount

$ Amount Currently Due

Food

$ Monthly Amount

$ Amount Currently Due

List All Other Expenses (click + to add more)

Other Expense

$ Amount Due

FILE UPLOAD

Upload Photo Files

Attach Your Proof of Address (such as Driver's License, Current Utility Bill, etc.) and Proof of Medical Diagnosis (if applicable).

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 20 MB.

CERTIFICATION

NOTE: This Form of Need is used by the Outer Banks Relief Foundation, Inc. and its Board of Directors to determine the level of need and appropriate assistance. The Foundation, while sensitive to the confidential personal, financial and medical information you are providing in your request for assistance, must conduct an investigation and cannot and does not guarantee the confidentiality of the information you provide, or which may be provided. By requesting to be considered for assistance, you knowingly and voluntarily waive any and all privileges and confidentiality requirements whether under State or Federal law, and agree to hold the Foundation, and those who provide information to the Foundation, harmless from any and all liability for any disclosures of information provided to or obtained by the Foundation.

I have read the above statement and agree with Outer Banks Relief Foundation, Inc.’s confidentiality policy and in consideration of their acceptance and consideration of my Form of Need, agree to be bound by the terms thereof. I also certify that the information I have provided in my Form of Need and any other information provided to the Outer Banks Relief Foundation is true and correct to the best of my knowledge. Furthermore, I agree that if I am awarded relief funding and I do not use those funds within 6 months of the award date, the balance is forfeited and will become Relief Foundation unrestricted funds. I may apply again for relief funding if circumstances make me eligible.

Candidate’s Signature*

Date*

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

CANDIDATE'S PERSONAL INFORMATION

FAMILY STATUS

OBRF CANDIDATE'S CIRCUMSTANCE / STATEMENT OF NEED

HOUSEHOLD INCOME INFORMATION (Include ALL)

OTHER INCOME / BENEFITS

HOUSEHOLD EXPENSE INFORMATION

FILE UPLOAD

CERTIFICATION

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