Call Us:

661-470-0072

Email:

nannieshouseinc8889@gmail.com

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Financial Assistance

Financial Assistance Intake Form

Nannies House Inc Inc. is here to provide support and shelter. Please fill in the form below so we can determine the best way to assist you. Thank you for reaching out to us!

Financial Assistance Intake Form

Financial Assistance Intake Form

(For Individuals Requesting Support)

Applicant Information

Full Name:(Required)

Date of Birth:(Required)

MM slash DD slash YYYY

Gender:

Phone Number:

Email Address:(Required)

Current Address:

City:

State:

Zip:

Household Information

Number of people in household:

Dependents (names & ages):

Marital Status:

Single

Married

Divorced

Widowed

Employment Status:

Employed

Unemployed

Retired

Student

Financial Information

Monthly Household Income:

Monthly Household Expenses:

Sources of Income:

Employment

Social Security

Unemployment

Other

Do you currently receive assistance from other organizations?

Yes

No

Reason for Request

Please describe your current situation and why you are requesting financial assistance:(Required)

Amount of Assistance Requested:(Required)

How will this assistance be used? (e.g., rent, utilities, medical bills, food)(Required)

Supporting Documentation (attach copies if applicable)

Proof of Income (pay stubs, benefits statement, etc.)

Proof of Expenses (rent/mortgage, utility bills, etc.)

Identification (Driver’s License, State ID, Passport)

Other:

Proof of Income (pay stubs, benefits statement, etc.)

Max. file size: 1 GB.

Proof of Expenses (rent/mortgage, utility bills, etc.)

Max. file size: 1 GB.

Identification (Driver’s License, State ID, Passport)

Max. file size: 1 GB.

Other

Max. file size: 1 GB.

Consent & Acknowledgment

I certify that the information provided is true and complete to the best of my knowledge. I understand that providing false or misleading information may disqualify me from receiving assistance.

Signature

Date

MM slash DD slash YYYY

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Contact Us

661-470-0072

nannieshouseinc8889@gmail.co

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Home
About
Services
Reviews
Apply for
- Financial Assistance
- Volunteership
Contact

Home
About
Services
Reviews
Apply for
- Financial Assistance
- Volunteership
Contact

Home
About
Services
Reviews
Apply for
- Financial Assistance
- Volunteership
Contact

Home
About
Services
Reviews
Apply for
- Financial Assistance
- Volunteership
Contact

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