Application for Assistance

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Application for Assistance

IMPORTANT: Please fill out the form completely. Note that not all requests can be fulfilled; however, the committee will do its best to accommodate your needs. Please note the following:

  1. Checks will not be written directly to the applicant.

  2. Checks will be written directly to the agency, vendor, or landlord, etc.

  3. A copy of the bill or invoice MUST be attached to this application.

  4. All information provided by the applicant must be truthful. Any information that is deemed to be false will render this application null and void.

  5. The members of the Krewe of Apollo AIDS/Crisis Committee are the only authorities, at its discretion, to approve funding to applicants.

Name: ___________________________________ Home Address: ___________________________ ___________________________

Phone Numbers: ____________________ (Home) Who Referred You: ________________________ ____________________ (Cell)

Have you tested HIV+ ________

If you are not HIV+, please give the circumstance for needed assistance ____________________________

Have you ever received assistance from the Krewe of Apollo AIDS/Crisis Fund? _____________________

Have you contacted other agencies for assistance? __________

If so, list which ones, the date(s) contacted and what responses they gave?

Do you currently have health insurance? _______ With whom? _____________________________

Are you currently employed? ______________ Full/Part time: ______________________________

Are you classified as disabled or unable to work? __________

If yes, do you currently receive disability payments? ___________

Are you eligible for Medicare or Medicaid? ___________________________________

How can we help you? __________________________________________________________________

What are your most urgent needs? _________________________________________________________

Please provide an estimated dollar amount of this request.* $________________________

*NOTE: The allocation of funds may be in full or a partial payment of the requested amount.

By signing this application, I attest that information provided is truthful. I understand that any false statements will deem this application null and void.

Date Applicant Signature

(The information contained on this form is for Committee use only and MUST NOT be divulged to anyone outside of the AIDS/Crisis Committee. The applicant shall be assigned a Case Number by the Committee for identification in dealing on the applicant’s behalf with anyone outside the Committee.)

Revised 9/10/2010 CASE NUMBER: ___________________

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