Hope Fund Application | The Community Caring Collaborative

General Information

Provider Name*

Provider Email*

Provider Agency*

Provider Phone*

Client/Family Name*

Client/Family physical address*

Number of children*

Ages of all household members*

At least one child must be prenatal to age 8

age of child 1	age of child 2	age of child 3

Request/Need Information

History*

Brief family history and description of need or barrier.

Goal*

What is the goal the family is working on?

How does the Hope Fund support reaching this goal?*

Requested amount

Requests for services already rendered or goods already purchased will be denied.

Resource already explored and outcomes

Please indicate below which resources have already been considered or pursued and whether the results were "n/a," "denied," "granted in part," etc.

General Assistance	DHHS Emergency Assistance	Downeast Community Partners	Shaw Fund	Robbie Fund	Family	Other

Categorize your request

Please categorize your request according to the following areas

Addresses a safety issue
Contributes to visitation or permanency outcomes
Prevents a family crisis
Supports child development
Supports employment/career goals
Increases access to services or opportunities
Addresses unmet basic needs
Other (please fill in below)

Other

Please be specific

Justification for this specific item/need and Consequences if denied*

What are the consequences for the family if this request is denied?

Additional Documentation

All requests must include invoice or estimate for repair, purchase, or services. Auto repair requests must include the cost of inspection. If combining Hope Fund with other resources to complete a purchase or project, you must fill out the Combined Funding Budget form below. If request commits family to future payments (e.g., security deposit or down payment) you must fill out the Household Budget form below. Supporting medical/dental/mental health information from a health professional is required for medical requests.

Upload documents here

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, xls, docx, xlsx, , Max. file size: 32 MB.

Tips for uploading documents

If your client needs to submit a photo of a bill as part of the family's application, ask them to use the flash when taking the photo, and to email you the photo (large size is best) instead of texting you, if possible. Emailed photos are much clearer than texted photos which can be very hard to read.

Combined Funding Budget Form

Use only if you are combining your request from other sources. Only fill in the line items that apply to this request/need. Total costs must equal total funding. Do not fill this out if the Hope Fund is the only funding source for the request/need. To use this form, click on the link below and download to your computer and save. Fill out the form saving your changes, and upload with any supporting documentation in the space provided above.

Please click to complete the combined funding budget form.

Monthly Household Budget Form

Use only if the request commits family to future payments. Use figures that do not include requested support. To use this form, click on the link below and download to your computer and save. Fill out the form saving your changes, and upload with any supporting documentation in the space provided above.

Please click to complete the monthly household budget form.

Other information the committee may need to make a determination?

Payment Information

must be completed

Vendor/Landlord Name

Address

Street Address Address Line 2 City State ZIP Code

Permission to contact for follow-up interview (optional)

not participating in a follow-up interview will have no impact on the funding decision. You may change your mind about participating in the follow-up interview at any time.

I do not wish to participate in a follow-up interview
I agree to participate in a follow-up interview to review my experience with the program.

Client/Family Signature*

please print your name - this will be your e-signature

Client/Family Email

Provider Signature*

Please print your name - this will be your e-signature

Date

Please Note:

A multi-agency committee of the Community Caring Collaborative reviews applicant information. The CCC encourages providers to arrange for necessary releases of information.

I have read this notice.

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