Emergency Assistance Application Form – Copyright © 2026 Rescue 100. All rights reserved.

Instructions

Please complete all sections of this application as accurately as possible. The information provided will remain strictly confidential and will only be used to determine eligibility for financial assistance. Submitting an application does not guarantee funding.

SECTION 1: APPLICANT INFORMATION

Name

First

Middle

Last

Full Legal Name

Contact Member need.

Who Referred you to this application?

If other in Who Referred you, please give their name or organization's Name

Contact information for "Other" Phone Number and/or Email

Phone

Email

Date of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

SECTION 2: HOUSEHOLD DEMOGRAPHICS

List all individuals currently living in your household, including children:

Total Number of Adults in House Hold

Total Number of Children (under 18) in Household

Full Name of House Hold Member 1

Relationship of Member 1

SECTION 3: FINANCIAL OVERVIEW

Total Monthly Household Income (All Sources Combined):

Total Dollar Amount Employment / Wages

Total Amount of Child Support / Alimony

Total Amount of SSI / SSDI

Total Amount of TANF / SNAP

Checkboxes

I have no Current Income Source

SECTION 4: ASSISTANCE REQUEST DETAILS

Total Amount of Financial Assistance Requested:

Type of Emergency Need (Check all that apply)

Rent / Housing Eviction Prevention
Utility Shut-off Prevention (Water, Gas, Electricity)
Medical Bills / Emergency Healthcare
Essential Groceries / Food Disruption
Transportation / Vehicle Repair for Work
Other

Other Type Explained

Briefly describe the emergency or crisis that caused this financial need.

SECTION 5: VENDOR PAYMENT INFORMATION (IF APPLICABLE)

To ensure IRS compliance, our organization prefers to pay vendors directly whenever possible.

Name of Landlord / Utility Company / Vendor:

Vendor Account Number (if applicable):

Vendor Payment Address / Phone:

SECTION 6: REQUIRED VERIFICATION CHECKLIST

Please attach copies of the following documents to this application if it has not already been provided to the requesting organization:

Check all type of Files Being uploaded.

Photo ID for the primary applicant (Driver’s license, state ID, or passport).
Proof of income (Last 2 paystubs, tax return, or benefit award letter).
Proof of financial emergency (Eviction notice, past-due utility bill, or repair estimate).

File Upload

Drag & Drop Files, Choose Files to Upload You can upload up to 6 files.

SECTION 7: APPLICANT ACKNOWLEDGMENT AND SIGNATURE

By signing below, I certify that all information provided in this application is true, accurate, and complete to the best of my knowledge. I understand that providing false information will result in the immediate denial of assistance.

I further understand that this assistance is provided as a charitable grant based on the availability of organizational funds, and that funds must be used strictly for the emergency purposes outlined above.

Requesting Organization:

Electronic Signatures Acknowledgment

By typing my/our name(s) below, I/we acknowledge and agree that this constitutes my/our valid electronic signaturs and is the legally binding equivalent to my/our handwritten signature. I/We further agree that my/our electronic signature is valid and enforceable for all purposes.

Print Requesting Organization Representees Name

Organization Representee Acknowledgment: By checking this box I agree that my typed name below serves as my legal signature.

By checking this box I agree that my typed name below serves as my legal signature.

Signature Date:

Print Applicant Name

Applicant Acknowledgment: By checking this box I agree that my typed name below serves as my legal signature.

By checking this box I agree that my typed name below serves as my legal signature.

Signature Date:

GDPR Agreement

I consent to having this website store my submitted information so they can respond to my inquiry.