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Request for Funds
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Form request number if applicable
Your answer
Funds requested
Your answer
Date
MM
/
DD
/
YYYY
Referrer name
Your answer
Referrer email address and phone number
Your answer
Agency
Your answer
Mailing Address of Agency
Your answer
Funds payable to (Payee must not be a client)
Your answer
County jurisdiction of child(ren)
Lehigh
Northampton
Other:
Clear selection
In what city do(es) the child(ren) live?
Your answer
Is/Are the child(ren) in legal custody of the county and placed in kinship/foster care?
Yes
No
Clear selection
Number of children in family
Choose
1
2
3
4
5
6
7
8
9
10
Age(s) of Children
Your answer
Specific need requested
Your answer
Number of twin beds requested
Your answer
Number of bunk beds requested
Your answer
Number of full beds requested
Your answer
Are any full beds requested for adults?
yes
no
Clear selection
Number of futons requested
Your answer
Number or toddler beds requested
Your answer
Number of cribs requested
Your answer
List any additional furniture being requested
Your answer
If furniture was requested was it from:
Glazier's
Milano's
Other
No Furniture Requested
Clear selection
Is bedding requested?
yes
no
Clear selection
If bedding is requested, please list the size and quantity needed
Your answer
Is this request related to a COVID-19 hardship
Yes
No
Clear selection
Is any part of this request not for children?
Yes
No
Clear selection
If any part of this request is for an adult, please explain
Your answer
Explanation of the family's situation
Your answer
Does the family get welfare assistance?
Yes
No
Clear selection
If the family gets welfare assistance, what assistance do they receive?
Cash
Food Stamps
Medical Assistance
Clear selection
What is the family's yearly income?
Your answer
Please list other agencies working with the family
Your answer
Please list any other resources that have been explored
Your answer
This form has been updated 12/7/2021
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