Helping Grandparents as Parents

Name of person applying for assistance:

Last_______________________________________ First ___________________________________________

Social Security Number _________________________________________

Home Telephone # _____________________________ Work Telephone #____________________________

Address ____________________________________________________________________________________

City _____________________________________________ Zip Code __________________________________

2. Purpose of request (use additional pages if necessary) ________________________________________

____________________________________________________________________________________________

3. Those who will be benefiting from this gift if received: (Name, age and birthday of each person)

______________________________________________ __________________________________________

4. Please list all sources of income:

Employment earnings per year $____________________ Child support $____________________

Governmental aid $______________________________ Other $_____________________________

5. List your employer's name, address, and phone number:

__________________________________________________ ( )__________________________

__________________________________________________

6. Please fill in all that apply:

Bank accounts $______________________________ Mortgage or rent $ ______________________________

Car payments $ ______________________________ Debts $ ________________________________________

Car ________________________________________ Medical bills $ _________________________________

Other $______________________________________ Other $________________________________________

7. How did you hear about Helping Hands Helping Others? ________________________________

8. Do you have custody of your grandchildren? __________________________________________

I verify that the above information is true and correct as of the date of my signature. I understand that the information

provided on this form will be the bases for assistants and any false or misleading information will result in ineligibility.

Proof of information given will be require before any assistance can be awarded. I give consent to Helping Hands

Helping Others to obtain any information deemed in connection with this application.