Grants for Financial Assistance Credit Card Debt

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					                                                                                                                                                        Family Services of RI
                                                                                                                                                        Attn: Alex Batista
Application for Financial Assistance                                                                                                                    55 Hope Street
                                                                                                                                                        PO Box 6688
877-748-3700                                                                                                 www.stationfamilyfund.org                  Providence, RI 02940



The Station Family Fund was founded by survivors and                                      • Assistance with public utility costs, including
family members affected by The Station nightclub fire                                       electricity and heating, especially to prevent
of February 20, 2003. We provide financial grants to                                        termination of service
those who suffered injury in the fire, or offer occasional                                • Emergency assistance to pay for food
financial assistance to individuals or families who, as a                                 • Children’s daycare
direct cause of the fire, are no longer self-sufficient.                                  • Transportation to and from doctors
                                                                                            appointments
Grant requests will be processed by Station Family
                                                                                      Generally, the Fund does not provide grants for:
Resource Center. All decisions will be made by the
                                                                                          • Financial difficulties stemming from a
Board of Directors. Priority will be determined based on
                                                                                            situation or event before the time of the fire
the severity of disability or impairment and financial
                                                                                          • Job loss not related to the fire and financial
hardship. If approved, grants are paid directly to                                          hardship arising from that job loss
service providers such as doctors, dentists, insurance                                    • Repayment of loans to family and friends
or mortgage companies, daycare centers or landlords.
                                                                                          • Car insurance, car repairs or the purchase
                                                                                            of new vehicles
Eligibility for Financial Assistance                                                      • Cable TV or Internet service
Grants are considered on a case-by-case basis. They                                       • Clothing and accessories for children or adults
may be issued to those who have exhausted all viable                                      • Tuition expenses and school supplies
financial resources, including savings accounts, loans                                    • Attorney fees
and government-assistance benefits, and still face dire                                   • Purchasing items or procedures not covered
financial hardship as a result of the fire.                                                 by your medical or dental insurance
                                                                                          • Home repairs
You Must Meet the Following Criteria:
  • The hardship is through no fault of your own
                                                                                      To Apply For a Grant
  • You have managed your finances satisfactorily                                     Complete this application and attach the required
  • You have no other financial resources available                                   supporting documentation; please submit the
    to you or you have already exhausted those                                        information to:
    resources (e.g., employment, savings, retirement
    fund, loans, other social services)                                               Family Services of RI
                                                                                      Attn: Alex Batista
Qualifying Hardships                                                                  55 Hope Street
Generally, the Station Family Fund may issue grants                                   PO Box 6688
to help with:                                                                         Providence, RI 02940

  • Assistance to prevent eviction or foreclosure.                                    Applications may also be submitted via
    The fund may pay a maximum of two months’                                         www.stationfamilyfund.org/help.html
    rent or two mortgage payments, not to exceed
    $3,000 per year                                                                   The Station Family Fund Board of Directors will review
  • Medical or dental bills related to the fire,                                      each request for funding and notify applicants of its
    copayments or coinsurance                                                         decision as soon as possible, usually within 30 business
  • Medical supplies related to the fire                                              days.
  • Prescription expenses related to the fire
  • In- or outpatient mental health services, including
    addiction medicine




                 The Station Family Fund is an all-volunteer, non-profit 501(c)(3) charitable organization. Every dollar raised by the Station Family
                 Fund, Inc. goes directly to address the needs of the survivors and the families of victims impacted by The Station nightclub fire.
                                                                                                                                                                 Family Services of RI
                                                                                                                                                                 Attn: Alex Batista
Application for Financial Assistance                                                                                                                             55 Hope Street
                                                                                                                                                                 PO Box 6688
877-748-3700                                                                                                          www.stationfamilyfund.org                  Providence, RI 02940




                                                                                                                                             Date of Application:


Applicant’s First Name                                                       Last Name                                                       Date of Birth


Applicant’s Address                                                                                                                          Apt. #:


City                                                                                                       State                             Zip Code
Do you:         I        Rent             I      Own


Home Phone                                                  Cell Phone                                             Work Phone
(Please include area code)


Applicant’s Email Address


Best method to contact
(Please include times)


Applicant’s Place of Employment
I Full Time        I Part Time


Relation to the Fire:           I   Survivor                I     Spouse of Deceased                       I     Child of Deceased                    I     Other


If other please explain


Name of Deceased


Are You:                  I     Single             I     Married                 I     Divorced                    I      Separated                   I     Widowed


Spouse’s First Name                                                                  Spouse’s Last Name


Spouse’s Place of Employment
I Full Time        I Part Time

Child’s First Name                                                    Child’s Last Name                                                                   Age


Child’s First Name                                                    Child’s Last Name                                                                   Age


Child’s First Name                                                    Child’s Last Name                                                                   Age


Child’s First Name                                                    Child’s Last Name                                                                   Age


Place of employment for children of legal age
I Full Time      I Part Time

Please describe your disability or situation:




                          The Station Family Fund is an all-volunteer, non-profit 501(c)(3) charitable organization. Every dollar raised by the Station Family
                          Fund, Inc. goes directly to address the needs of the survivors and the families of victims impacted by The Station nightclub fire.
                                                                                                                                                                 Family Services of RI
                                                                                                                                                                 Attn: Alex Batista
Application for Financial Assistance                                                                                                                             55 Hope Street
                                                                                                                                                                 PO Box 6688
877-748-3700                                                                                                          www.stationfamilyfund.org                  Providence, RI 02940




Description of Financial Hardship                                                              Each application must include the following
                                                                                               documentation:
                                                                                               I Copy of most recent tax return
Please attach a letter describing the reason for your
financial distress, including:
    • What happened to cause the situation?                                                    I Last three months’ checking account statements
    • To whom did it happen and when?                                                          I Last month’s pay statements from all employers
    • How did it happen?                                                                       (full-time, part-time, temporary)

Please indicate how you’ve tried to resolve your                                               I Proof of other income (pay statements from other
financial hardship.                                                                            members of your household; child support; alimony;

I Taken other jobs or worked additional hours
                                                                                               unemployment, SSI/SSDI, etc.)
                                                                                               I Copies of bills or receipts to be considered
I Cut back on household expenses to save                                                       for payment (foreclosure/eviction notices; utility bills
  money                                                                                        and shut-off notices; medical, dental and pharmacy
I Consolidated debt, paid off loans and                                                        bills; receipts from daycare centers, etc.)
  high-interest credit cards                                                                   I Please provide all medical information including
I Borrowed from family members                                                                 original diagnosis from doctor, treatments, therapy,
                                                                                               medications, etc., if you are unable to work because
I Applied for assistance such as SSI                                                           of a disability, injury or other medical condition.




Personal Financial Statement                                                                   Monthly Financial Management Worksheet
Assets                                              Amount       (Omit Cents)                  Monthly Income                                      Amount         (Omit Cents)


Checking account balance:                       $                                              Monthly Salary:                                 $

Savings account balance:                        $                                              Other household income(s):                      $

Retirement Plan balance:                        $                                              SSI benefits:                                   $
(401(k), IRA, pension, etc.)

Cash-value life insurance:                      $                                              Child support/alimony:                          $
                                                                                               (please specify)

Cars/trucks:                                    $                                              Savings contributions:                          $

Real estate owned:
                                                                                               Monthly expenses                                    Amount          (Omit Cents)

Estimated value:                                $                                                                                              $
                                                                                               Mortgage/rent:

Other assets:                                   $                                                                                              $
                                                                                               Property tax

Total estimated net worth:                      $                                                                                              $
                                                                                               Homeowners/renters insurance:

Basic Income Statement                              Amount       (Omit Cents)
                                                                                               Life insurance:                                 $

Applicant’s Salary:                             $
(Gross annual)                                                                                 Medical expenses:                               $
                                                                                               (out of pocket, for self and/or family)
Spouse’s Salary:                                $
(Gross annual)                                                                                 Heat/fuel:                                      $

Rental income (annual):                         $
                                                                                               Electricity:                                    $

SSI benefits (annual):                          $                                                                                              $
                                                                                               Telephone (landline):

Other annual income:                            $
                                                                                               Cell phone(s):                                  $

Total annual income:                            $                                                                                              $
                                                                                               Total monthly expenses:



                          The Station Family Fund is an all-volunteer, non-profit 501(c)(3) charitable organization. Every dollar raised by the Station Family
                          Fund, Inc. goes directly to address the needs of the survivors and the families of victims impacted by The Station nightclub fire.
                                                                                                                                                           Family Services of RI
                                                                                                                                                           Attn: Alex Batista
Application for Financial Assistance                                                                                                                       55 Hope Street
                                                                                                                                                           PO Box 6688
877-748-3700                                                                                                    www.stationfamilyfund.org                  Providence, RI 02940




Monthly Financial Management Worksheet
Monthly expenses                              Amount        (Omit Cents)                 Outstanding Debts                                      Amount        (Omit Cents)


Total expenses from page 3:               $                                              Personal loans:                                 $
                                                                                         (total amount outstanding)

Groceries:                                $                                              Amounts past due:                               $

Meals out:                                $                                              Credit card balances (list individually):

Child care:                               $                                              Card #1:                                        $

Child support:                            $                                              Card #2:                                        $

Car loans:                                $                                              Card #3:                                        $

Car insurance:                            $                                              Card #4:                                        $

Gasoline:                                 $                                              Amounts past due:                               $

Public transportation:                    $                                              Mortgage/rent amount past due: $

Clothing/shoes:                           $                                              Medical bills amount past due:                  $

Entertainment:                            $                                              Phone amounts past due:                         $

Vacation/travel:                          $                                              Utilities past due:                             $

Children’s activities:                    $                                              Other past due expenses:                        $

Pet/veterinary expenses:                  $                                              Other past due expenses:                        $

Health club membership:                   $                                              Total outstanding debts:                        $

Other:                                    $

Other:                                    $
                                                                                          Total monthly income:                             $

Total monthly expenses:                   $
                                                                                          Total monthly expenses:                subtract   $

                                                                                          Monthly debt payments:                 subtract   $

                                                                                          Total shortfall:                                  $




I certify that the information I have provided in my application is true to the best of my knowledge.



Signature                                                                                                                 Date




                    The Station Family Fund is an all-volunteer, non-profit 501(c)(3) charitable organization. Every dollar raised by the Station Family
                    Fund, Inc. goes directly to address the needs of the survivors and the families of victims impacted by The Station nightclub fire.

				
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