PLACE Gives Grant Application Form
PLACE Gives is aimed to serve our PLACE community by mobilizing funds to those within our organization experiencing hardships. “Hardship” is defined as a difficult circumstance that a member of our community cannot handle without outside help. To qualify for a PLACE Gives grant, requestor must have been a member of PLACE for at least 6 months and funds are granted to requestor/immediate household family members only. 

Grants are evaluated on a case-by-case basis and are subject to the approval of the PLACE Gives board of directors. Any grant application may be subject to verification of the financial need of the proposed recipient through federal income tax returns and/or pay stubs. The board of PLACE Gives reserves the right to request any other pertinent information or documentation to determine eligibility.
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Email *
What is the date of the request? *
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What is the applicant's first and last name? *
What date did the applicant first start with PLACE? Our bylaws require to be with PLACE or an affiliated company for six months or more prior to application.
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What is the applicant's role within PLACE? *
What is the applicant's address? Please provide street number, street name, city, state and zip code. *
What is the applicant's phone number? If no phone, please give a name & phone number where a message can be left. *
Who is the applicant's employer? If unemployed, what is the last date of employment? *
Please provide employer city and phone number. *
What is the applicant's marital status? *
Who referred the applicant to the organization? Please provide name, address and phone number. *
Has the applicant received assistance from other organizations? *
If the applicant has received assistance from another organization, please provide the following information: date provided, where provided and type of assistance. *
What is the name and phone number of the applicant's insurance company *
May we contact the insurance company? *
How much of the estimated cost will the insurance company cover? *
Is the applicant eligible for Medicaid or Medicare? *
Please provide the total income of the applicant.  *
Is the applicant an hourly, salary or 1099 employee? *
Is the income above weekly, monthly or annual? *
Is the applicant receiving any type of aid? *
What are the monthly rent or mortgage expenses? *
What are the monthly food expenses? *
What are the monthly utility expenses? *
What are the monthly credit card expenses? *
What are the monthly medical insurance expenses? *
What are the monthly car(s) payment(s)? *
What are any other recurring monthly expenses? *
What amount of assistance is requested from PLACE Gives *
Please describe in detail how the funds will be used. *
What is the urgency of need?  *
Does applicant currently have a doctor or medical provider? *
The PLACE Gives board reviews grant applications twice per month. Please indicate if this need is immediate/urgent.  *
If the applicant currently has a doctor or medical provider, please provide the name, complete address and phone number of the doctor or medical provider. *
I, the applicant understand that I may be interviewed by telephone, or in person, if additional information or clarification is needed. I have answered all of the questions to the best of my ability. *
By hitting submit, you are authorizing this application to be reviewed by the board and all of the information provided is correct.  *
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