FORM — Steps Together

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

(###)

###

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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)

(###)

###

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DOES BENEFICIARY WORK OR RESIDE IN SOMERSET, HUNTERDON, MERCER, MIDDLESEX, UNION or MORRIS COUNTY?

YES

IS BENEFICIARY UNDER THE AGE OF 20 OR HAVE DEPENDENTS UNDER THE AGE OF 20? PLEASE LIST

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