FAMILY HEALTH GARDEN
FINANCIAL AID APPLICATION

Personal Information:
- Full Name: ____________________
- Date of Birth: ________________
- Social Security Number: _______
- Phone Number: ________________
- Email Address: ________________
- Home Address: ________________

Household Information:
- Household Size: _______________
- Number of Dependents: _________
- Marital Status: _______________

Income Information:
- Current Monthly Income: _______
- Employment Status: ____________
- Employer Name: _______________
- Other Income Sources: _________

Expenses (Monthly):
- Rent/Mortgage: _______________
- Utilities: ___________________
- Food: _______________________
- Transportation: ______________
- Medical: ____________________
- Other: ______________________

Type of Financial Assistance Needed:
□ Utility Payment Assistance
□ Rent/Mortgage Assistance
□ Food Assistance
□ Medical Bill Assistance
□ Transportation Costs
□ Other: ______________________

Amount Requested: $_____________

Explanation of Need:
_________________________________
_________________________________

Required Documents (please attach):
□ Proof of Income
□ Utility Bills
□ Rent/Mortgage Statement
□ Identification

Signature: _____________________ Date: _________

Submit to: info@familyhealthgarden.com