Request for
ASSISTANCE

Request for Assistance

Please use the following form to introduce yourself or someone you know to request emergency assistance or general assistance for assistance.
Your request should describe the need, frequency of support, duration of support, and amount requested.
Our organization staff will carefully review your request, and you will receive a reply within 45 days for General Assistance Requests, College for Dreamers, or purchase of items
For Emergency Assistance a reply will be sent within 72 hrs.
If applying for general assistance, please be advised that you may be asked to provide more details about your request before a funding decision is made.

Grantee First Name

Grantee Last Name

Do you have SSN# or ITIN# (If so, select the one that applies)

SSN#

ITIN#

Phone*

Prefered contact method:

Phone

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Location of Receipent:

FUNDING REQUEST OVERVIEW

Funding Purpose or Funding Type: (Please Check all that apply)

Emergency Assistance

Educational Assistance

General Assistance

If General Assistance is chosen, please identify need

Funding Request Details

AMOUNT REQUEST

Please indicate the frequency of payments requested, length of time support will be needed, amount of each payment, and total amount being requested:

How often will payments be needed:

One Time

Recurring

How often will payments requested (Choose number and length of time )

Amount of each payement:

Total Amount Requested:

ADDITIONAL INFORMATON

GENERAL CONDITIONS
Applicants (the “Applicant”) for this Request Summary (the “Application”) are hereby advised that nothing herein nor any communication made between The Heart Channels or its representatives and the Applicant, or any part thereof, shall be taken as constituting a contract, agreement or representation between The Heart Channels and the Applicant and/or any other party (save for a formal donation agreement made in writing by The Heart Channels), nor shall it or they be taken as constituting a representation that a contract or donation agreement shall be offered or awarded. The Applicant is hereby advised that The Heart Channels makes no commitment whatsoever that any potential partner will be selected as a result of the Application. The Heart Channels makes no commitments, implied or otherwise, that this process will result in a donation transaction with one or more parties and reserves the right to modify the intended scope at any time.

If your application is selected for funding, the awarded applicant will be subject to donation usage reports by The Heart Channels. As part of the reporting requirements, the awarded applicant will be subject to a review of transaction documents, including but not limited to actual receipts, invoices, and breakdown of transactions.

Additionally, awarded applicants will be asked to provide progress reports indicating that they meet any expectations or terms outlined in the donation agreement based on the type of funding awarded. We ask that you only report progress directly attributable to The Heart Channels funding.

The Heart Channels reserves the right to verify any information contained and submitted in the Application and Applicant’s response, and to request additional information after the Application has been submitted.

By submitting this proposal for the Application, you expressly agree to the terms and conditions stated above in the General Conditions of the Application.

I accept terms & conditions

Thank you for applying. We will get back to you soon,

Request for
ASSISTANCE