PHARE Grant Online Application

"*" indicates required fields

Applicant Information

PLEASE NOTE: In order to be eligible for this program, your household income must be less than $59,396 annually.

Name*

First Middle Last

Today's Date*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Amount of funds you are seeking:*

Funds will be utilized toward:*

Rent/Mortgage

Utilities

Pest Eradication

Transportation Costs (vehicle repairs, Uber gift cards, bus passes, etc)

Required Information

Landlord Name

First Last

Landlord Phone:

Please attach a copy of your lease

Max. file size: 256 MB.

Please attach a copy of W-9, completed by landlord

Max. file size: 256 MB.

Please attach Proof of Need from landlord

Max. file size: 256 MB.

Utility Company:

Utility Account Number:

Please attach a copy of your most recent bill

Max. file size: 256 MB.

Have you been sent to a consumer's home where bed bugs were known to be a problem?

Yes

Please attach a copy of your vehicle registration

Max. file size: 256 MB.

Household Information

How many adults in household:

How many children in household:

Proof of annual income for entire household:

Drop files here or

Max. file size: 256 MB.

You can upload multiple files here, to reflect multiple incomes within the household

Additional Information

Please describe fully why you are in need of financial assistance (tell your story) here:*

Name of PAS Supervisor (this is a VFI PAS Supervisor who is aware of my current financial situation and can assist in processing my application by signing off on my story):

Disclaimer and Signature

Name

This field is for validation purposes and should be left unchanged.