Grant Application Form

New Start Grant Application

IF YOU HAVE NOT READ OUR NEW START GRANT APPLICATION GUIDELINES, PLEASE DO SO before completing the application!
You MUST have a Case Manager and currently be receiving services from the agency submitting the request.
PLEASE COMPLETE EACH OF THE FOLLOWING QUESTIONS IN FULL AND SUBMIT THE FORM USING THE "SUBMIT" BUTTON BELOW.

1. Case Manager Making Referral *

First

Last

2a. Phone Number *

2b. Extension *

3. Email *

4. Agency Name *

5. How long has the applicant been a client and what is your role in your client’s situation? *

6. Client Name *

First

Last

7. Has the applicant/client received a New Start grant in the past? *

Yes No

8. Does the applicant/client currently live in Western North Carolina? *

Yes No

9. New Start is a “last resort” fund. We ask that other sources of funding for this need be explored before submitting a request. Please list all local agencies/sources contacted for assistance regarding this need along with how much they have committed to providing or the reason why the request was declined. *

10. What initial problem or event led to your client’s current situation and need for financial assistance? *

11. What behavioral changes has your client made and what specific steps has she taken to begin her new start? *

12. New Start grants are not intended for use as a “stop gap”. We ask that a woman be ready to sustain her new start before applying for a grant. What specific plans does she have in place for a new start in her life? *

13. Does she have the necessary support in place that will enable her to sustain a new start? Specifically, what agency or agencies will continue to provide support for her? *

14. Please describe your client’s current housing situation. *

15. Are there other adults residing in the household? If so, what is their relationship to your client and/or the family? *

16. If your client has children, please indicate how many and their ages. *

17. Please provide your client’s current employment information. (Employer, location, number of hours per week, and wages) If unemployed, please explain why. When and why was previous employment terminated? *

18. Please provide any other pertinent information that you know regarding your client’s situation. *

19. One-time grants (per recipient) are available for the amount of need up to $600. Please indicate specifically what the grant is for. *

20. Checks are made payable to the vendor, not the individual. The name and mailing address of the vendor must be included for the grant to be processed. Please also include any other relevant information needed for payment. *

Submit

New Start Grant Application

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