FRESH START GRANT REQUEST FORM

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This form is for men and women who are starting off fresh in their new homes. Please fill this out in its entirety. Please note, Box of Blessings gives out a limited number of grants per year. If you aren't selected, a list of other resources will be provided to you.

Full Name *

Date of Birth *

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Current Address *

Email Address *

Phone Number *

Driver's License or State ID Number

Tell us about yourself. (Check all that applies) *

I am in/was in the U.S Military.

I have been a victim of domestic violence.

I am a foster child transitioning into adulthood.

I have been homeless within the last 6 months.

I was released from prison within the last 6 months.

I am a parent who has been reunified with my child/children within the last 6 months.

I was a victim of a housefire within the last year.

I completed drug and/or alcohol treatment within the last year.

Required

Please tell us why you are applying for the fresh start grant. Please give specific details about the circumstances that led up to where you are now. *

*I affirm that the information I provided on this form is truthful and accurate. (Please Initial Here) ___________ *

YYYY

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