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Financial Assistance Request Form Template

Streamline Your Financial Assistance Process with This Template

Struggling to manage numerous financial assistance requests can be overwhelming. This Financial Assistance Request Form Template helps non-profits, schools, and individuals clearly collect and assess support needs. With a user-friendly design, you can facilitate quicker approvals, ensure essential information is provided, and improve communication with applicants, all while staying compliant with data protection standards. Discover how easy it can be with this live template!

Use this Template (FREE) Live Preview
Full legal name
Date of birth
Email address
Phone number
Current address (street, city, state/province, postal code, country)
How many people live in your household?
1
2
3
4
5
6+
Prefer not to say
What is your average monthly rent or mortgage payment (in your local currency)?
What is your current housing status?
Rent
Own with mortgage
Own free and clear
Living with family/friends
Temporary/Transitional
Homeless/No fixed address
Prefer not to say
Other
Please Specify:
What is your current employment status?
Employed full-time
Employed part-time
Self-employed
Unemployed
Student
Retired
Unable to work
Prefer not to say
What is your approximate monthly gross income (before taxes)?
Do you receive any of the following income or benefits? (Select all that apply)
Unemployment benefits
Disability benefits
Social Security/retirement
Child support/alimony
Food assistance/SNAP
Housing voucher
None
Other
Please Specify:
What is your approximate total monthly essential expenses (housing, utilities, food, transportation)?
Which bills are currently past due, if any? (Select all that apply)
Please Specify:
Please describe your current financial hardship and how assistance will help
Approximate date your hardship began
Are you currently facing any of the following urgent issues? (Select all that apply)
Eviction notice
Foreclosure notice
Utility disconnection notice
None of these
Do you have documentation to support your request (e.g., bill, notice, statement)?
Yes
No
Not sure
How long do you expect assistance to be needed?
One-time
1-3 months
4-6 months
More than 6 months
Not sure
What type(s) of assistance are you requesting today? (Select all that apply)
Please Specify:
What is the total amount of assistance requested (in your local currency)?
If payment should go directly to a landlord, utility, or vendor, please provide payee name and account or invoice details
What is the status of any other assistance you have sought for this need?
Did not apply
Approved
Pending
Denied
Prefer not to say
What is your preferred contact method for follow-up?
Email
Phone call
Text message
No preference
Signature
Date signed
I confirm that the information provided is accurate to the best of my knowledge and I consent to be contacted about this request
Strongly disagree
Disagree
Neither
Agree
Strongly agree
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Paper art illustration depicting a financial assistance request form highlighting key sections and details

When to use this form

Use this form when someone needs short-term help to cover a specific expense. It works for nonprofits, schools, clinics, faith groups, and HR teams that provide emergency aid or hardship funds. Typical cases include rent to prevent eviction, utility shutoff notices, medical copays, funeral costs, or a student fee due this week. You collect the amount requested, the reason, deadlines, and proof, so you can triage and respond fast. For education-focused aid, pair it with a Financial aid application form. If you fund projects as well as individuals, route larger requests to a Grant application form. When help comes through corporate partners, connect this process with your Sponsorship request form.

Must Ask Financial Assistance Request Questions

  1. What type of expense do you need help with, and how much funding are you requesting?

    This defines the funding category and makes budgeting clear. It lets you compare requests and cap awards based on available funds.

  2. When is the payment due, and what are the consequences if it is not paid by that date?

    Due dates help you prioritize and triage urgent cases. Knowing the risk (eviction, power shutoff, enrollment hold) supports fair, time-sensitive decisions.

  3. What led to this need? Briefly describe your situation and the specific hardship or event.

    Context shows eligibility and impact, which improves review quality. For school-related needs, align criteria with your High school scholarship application form to keep policies consistent.

  4. Can you provide documentation to verify the amount and urgency (bill, estimate, notice, or invoice)?

    Proof reduces fraud and speeds approval because reviewers can verify amounts and deadlines. It also prevents back-and-forth later.

  5. Who should receive the funds, and how should we disburse them (payee name, address, and account or invoice details)?

    Paying the vendor directly reduces misuse and accounting work. Having complete payee details avoids delays and failed payments.

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