Furnishing Assistance Application Please complete the following application to request assistance with furnishing your home. We will review the application and contact you soon. Please enable JavaScript in your browser to complete this form.Contact Information - Step 1 of 3Your Name *FirstLastYour Email *Your Phone *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNextThe following questions provide information needed to complete the fundraising work that makes this program possible.Select your household's annual Income range *$0 - $15,000$15,001 - $25,000$25,001 - $35,000$35,001 - $45,000$45,001 - $55,000$55,001 - $65,000$65,001 or moreHow many people live in your household? *Are you a single parent? *Yes, I am a single parent with children living at home with meYes, 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 adultsNo, I am not a single parentAre you (or your spouse) a veteran? (copy) *Yes, I or my spouse are a veteranNo, not a veteranAre you (or your spouse) on disability? *Yes, I and/or my spouse are on disabilityNo, not on disabilityIf you were to purchase all the furnishings, would that put you at risk of being homeless? *YesNoPlease explain your situation *PreviousNextAre you a current client of Moneytalk Financial Foundations? *Yes, I am a current clientNo, this is my first interaction with MoneytalkNo, but I have been a client in the pastIn order to receive a furnishing assistance, participation in financial coaching or workshops is required. *I understand / AcknowledgeNo, I am not okay with thisHave you already completed a financial coaching session or workshop? *Yes, I have completed this requirementNo, but it is scheduledNo, I need to schedule a coaching sessionNo, I plan to attend a workshopWho 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. *Clear SignatureYour signature is confirmation that all the information provided is true and complete.Submit