Furnishing Assistance Application – MoneytalkFF

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Furnishing Assistance Application

Please complete the following application to request assistance with furnishing your home. We will review the application and contact you soon.

Contact Information - Step 1 of 3

Your Name *

First

Last

Your Email *

Your Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

The following questions provide information needed to complete the fundraising work that makes this program possible.

Select your household's annual Income range *

How many people live in your household? *

Are you a single parent? *

Yes, I am a single parent with children living at home with me
Yes, I am a single parent, but my children do not live with me. Furnishings would allow them to live with me.
Yes, I am a single parent, but my children do not live with me. Furnishings will not change this.
Yes, I am a single parent, but my children are adults
No, I am not a single parent

Are you (or your spouse) a veteran? (copy) *

Yes, I or my spouse are a veteran
No, not a veteran

Are you (or your spouse) on disability? *

Yes, I and/or my spouse are on disability
No, not on disability

If you were to purchase all the furnishings, would that put you at risk of being homeless? *

Yes
No

Please explain your situation *

Are you a current client of Moneytalk Financial Foundations? *

Yes, I am a current client
No, this is my first interaction with Moneytalk
No, but I have been a client in the past

In order to receive a furnishing assistance, participation in financial coaching or workshops is required. *

I understand / Acknowledge
No, I am not okay with this

Have you already completed a financial coaching session or workshop? *

Yes, I have completed this requirement
No, but it is scheduled
No, I need to schedule a coaching session
No, I plan to attend a workshop

Who referred you to us or this program? *

Anything else you would like to tell us?

The signature below will be considered your agreement and acceptance of the conditions of this program. *

Your signature is confirmation that all the information provided is true and complete.

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P O Box 860184, Shawnee, KS 66286

913-538-1465