Emergency Approval Request Form

Fill in the information and click submit. Information will be sent to all relevant members for approval.

Visit Type

Case Number

Case Type

Advocate

Second

Advocate Email

Friend First Name

Friend Last Initial

Adults

Children

Assistance that you are advocating for

Amount 1

Due Date 1

YYYY

Vendor 1

Amount 2

Due Date 2

YYYY

Vendor 2

Amount 3

Due Date 3

YYYY

Vendor 3

Amount 4

Due Date 4

YYYY

Vendor 4

Total Amount Requested

Gift Cards

List the total amount of any gift cards already provided to friend. Provide individual gift card numbers in the text field

Total, All Gift Cards

Gift Card Tracking Numbers (if any)

Friends Total Financial Recap

Income

Expenses

Hardship

Explain the hardship that necessitates the need for assistance. Include special circumstances such as eviction, unemployment/under employment, imminent utility disconnect, medical condition, special needs children, no child support etc.

Special Circumstances

Describe any expense special circumstances including but not limited to if the lease or bill is not in the Friends name, expenses not reasonable. Identify large, extraordinary expenses.

Need

Please explain the need for an Emergency Approval Request if the requested payment(s) due date is on or after the next scheduled meeting

Type of Check