Applicants must be referred to
EVFAF by a recognized social services agency or religious organization
|
Client Information |
Our
Office has received your request for assistance from the Eagle Valley
Family
Assistance Fund.
We are
a revolving loan fund which makes small, no interest, loans to working
people who live and/or work in Eagle County and who have had an unexpected
circumstance
occur
which has caused financial difficulty, such as ill health or a gap in
employment.
Because we need to be paid back in order to loan out funds to others, you
must have
verifiable, steady employment to qualify. Our requirements
for a loan are not as strict as those of a bank, but you do need to
demonstrate an ability to pay back. Our loans are
administered through the First Bank of Avon and, if you qualify for and
are granted a
loan, you
will sign a promissory note which legally obligates you to repay. The
repayment terms are decided upon by you and the bank
officer and are designed to be
doable
for you. However, this is a formal loan and is subject to collections if
you do not
repay.
We
have additional information concerning other Eagle County agencies that
might be
able to help you with your financial and social service
needs.
Please fill out the application form and call 524-1365.
A volunteer EVFAF Board member will phone you for an
interview.
We hope we will be able to assist you.
|
Please print
out the application pages below:
EAGLE VALLEY
FAMILY ASSISTANCE FUND
APPLICATION
FORM
Date:________________________________
Please fill out completely and call 524-1365 to set
up an interview with the EVFAF. Please bring the completed application with you
to the interview.
Name(s): 1. ____________________________ Age___ Birth
Date______________
2. ____________________________ Age___
Birth Date______________
Citizens? 1.
______ 2. ______
SS#_____________________
SS#______________________
Green Card? 1. #_____________________ 2.
#_______________________
Drivers License 1. #____________________ 2.
#________________________
(Please attach photocopies of all above cards.
Applications will not be processed with them).
Phone (H)_____________________________ Work
(1)____________________
Work (2)____________________
Physical Address____________________________________ How
long?___________
Mailing
Address_________________________________________________________
Previous Address____________________________________ How
long?___________
Family Members:
Children Living with You:
_______________________________________________Age___ Birth
Date________
_______________________________________________Age___ Birth
Date________
_______________________________________________Age___ Birth
Date________
_______________________________________________Age___ Birth
Date________
List children not living with you. Explain any custody
issues:
(1)_____________________________________________________________________
(2)_____________________________________________________________________
Parents:
(1)
Mother_________________________________Location/Phone______________
(1)
Father _________________________________ Location/Phone______________
(2)
Mother_________________________________ Location/Phone_____________
(3)
Father __________________________________ Location/Phone_____________
Nearest Relative:
(1)
______________________Relation_____Location/Phone___________________
(2)
_____________________ Relation_____Location/Phone____________________
Married? ________Date of Marriage_____
Place______________________
Years Married or
Together____________________________________________
Page 2
Church Affiliation/Name of
Church_____________________________________
Current Employment:
Position: How Long?
(1)___________________________________________________________________
Address/Phone:___________________________________________________
Immediate
Supervisor:______________________________________________
(2)___________________________________________________________________
Address/Phone:___________________________________________________
Immediate
Supervisor:______________________________________________
Previous Employment:
Position: How Long:
(1)____________________________________________________________________
Address:_________________________________________________________
Immediate
Supervisor:______________________________________________
Reason for
Leaving:________________________________________________
(2)____________________________________________________________________
Address:_________________________________________________________
Immediate
Supervisor:______________________________________________
Reason for
Leaving:________________________________________________
Medical History/Problems/Medications. Please
indicate both past and current:
(1)___________________________________________________________________
(2)___________________________________________________________________
Children:______________________________________________________________
______________________________________________________________________
Additional medical information, including outstanding
medical bills:
Education:
(1)_____________________________________________________________________
(2)_____________________________________________________________________
Substance/Spousal Abuse:
(1)_____________________________________________________________________
(2)_____________________________________________________________________
Arrests/Criminal Convictions:
(1)_____________________________________________________________________
(2)_____________________________________________________________________
Page 3
Assets:
Bank
Account:___________________________________________________________
Property/Residence:_____________________________________________________
_____________________________________________________________________
Vehicle: _______________________________ Year______
Make_________
Financed by:
_______________________________Address/Phone________________
When Purchased:____________ Total Cost ____________
Balance Owed_________
Vehicle: _______________________________ Year______
Make_________
Financed by:
_______________________________Address/Phone________________
When Purchased:____________ Total Cost ____________
Balance Owed_________
Other Assets:
Page 4
Monthly Income and Expense Worksheet:
Monthly
Income
Monthly Expenses:
Wages
(1)_____________ Fixed Expenses:
Wages
(2)_____________ Rent/Mortgage_______
Hourly
wage__________ Prop Tax/Insur_______
Hours/week____________
Trash______________
OT/week______________ Car
Payment________
Car Payment________
Child
support____________ Loan Payment_______
Interest/Dividends________ Loan
Payment_______
Social
Security___________ Loan Payment_______
Welfare_________________ Loan
Payment_______
Other___________________ Credit Card
Payment_____
Credit Card Payment_____
Health Insurance________
Day Care______________
TV___________________
Auto Insurance_________
Child Support/Alimony_____
Other___________________
Flexible Expenses:
Heating_________________
Electricity_______________
Water__________________
Telephone_______________
Cell Phone_______________
Food___________________
Transportation/Gas________
Car Mtc_________________
Education_______________
Personal Expenses________
Clothing________________
Savings_________________
Other___________________
Other___________________
Total Income
$_____________________ Total Expenses $__________
Notes/Explanations:
Page 5
Outstanding Debts:
Please indicate Husband (H), Wife (W), Joint (J):
Owed
To:
Amount:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Total
Outstanding Debts $_____________
Amount Requested from EVFAF $___________________
Money to be Used For:
__________________________________________________
_____________________________________________________________________
If any of the above information is found to be false, this
will constitute grounds for denial of this loan.
The above statements are true to the best of my knowledge:
(Signatures)
1.
_______________________________________________Date_________
2.
_______________________________________________Date_________
Page 6
For EVFAF Interviewers Only:
Names of
Applicants:______________________________________________________
______________________________________________________
Referred
by:_____________________________________________________________
Address____________________________________________________
Telephone__________________________________________________
Interviewers Comments:
Interviewers Evaluation:
Interviewers Contacts with Clients:
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