IN COMPLETING THIS APPLICATION ON BEHALF OF A BENEFICIARY, THEY MUST BE AWARE AND HAVE APPROVED THE SUBMISSION OF THE APPLICATION ON THEIR BEHALF. THE MORE INFO YOU CAN PROVIDE, THE BETTER WE CAN UNDERSTAND AND EXPEDITE YOUR NEED. APPLICANT NAME * First Name Last Name RELATIONSHIP TO BENEFICIARY APPLICANT EMAIL * APPLICANT PHONE (###) ### #### BENEFICIARY NAME (IF DIFFERENT) First Name Last Name BENEFICIARY ADDRESS Address 1 Address 2 City State/Province Zip/Postal Code Country BENEFICIARY PHONE (IF DIFFERENT) (###) ### #### DOES BENEFICIARY WORK OR RESIDE IN SOMERSET, HUNTERDON, MERCER, MIDDLESEX, UNION or MORRIS COUNTY? YES NO IS BENEFICIARY UNDER THE AGE OF 20 OR HAVE DEPENDENTS UNDER THE AGE OF 20? PLEASE LIST BENEFICIARY DATE OF BIRTH * PLEASE EXPLAIN THE MEDICAL CRISIS. (Example: date of diagnosis, diagnosis, treatment plan.) PLEASE DESCRIBE HOW THE FINANCIAL SITUATION HAS CHANGED. (Example: loss of work, high medical copays.) WHAT IS YOUR GREATEST NEED RIGHT NOW AND/OR HOW WOULD YOU USE THIS GRANT? ARE YOU RECIEVING SUPPORT FROM OTHER ORGANIZATIONS? (Please list) DO YOU HAVE A GO FUND ME, MEAL CHAIN OR ANYTHING WE CAN SHARE IN OUR NETWORK TO SUPPORT YOU? HOW DID YOU HEAR ABOUT STEPS TOGETHER? PLEASE SELECT GRANT TYPE I AM APPLYING FOR THE ONE TIME $1500 GRANT I AM APPLYING FOR ONGOING SUPPORT AND WILL PROVIDE SUPPORTING FINANCIAL DOCUMENTS CONFIDENTIALITY STATEMENT * BY SIGNING AND SUBMITTING THIS APPLICATION, YOU AGREE NOT TO PUBLICIZE THE AMOUNT AND TYPE OF ANY INITIAL GRANT OR SUBSEQUENT GRANT PROVIDE TO YOU BY STEPS TOGETHER. THIS INCLUDES, WITHOUT LIMITATION, SHARING THIS INFO WITH OTHER PAST, CURRENT OR PROSPECTIVE STEPS TOGETHER BENEFICIARIES. I AGREE I DISAGREE Thank you!