Request Assistance

Applicant Name Please enter valid data.

Address Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Email REQUIRED Please fill out this field. Please enter an email address.

HOUSEHOLD INFORMATION

Spouse Name Please enter valid data.

Is your spouse living at home? Yes No

Provide names, ages, and relationship to you, of everyone living at home. Please enter valid data.

Living Situation REQUIRED Please fill out this field.

Monthly Payment for Housing Please enter valid data.

FINANCIAL INFORMATION

Are you employed? Full-time Part-time Unemployed

Employer Name (Applicant) Please enter valid data.

Hours Worked Per Week (Applicant) Please enter valid data.

Is your spouse employed? Full-time Part-time Unemployed

Employer Name (Spouse) Please enter valid data.

Hours Worked Per Week (Spouse) Please enter valid data.

List any other people in your household who are employed, the hours per week they each work and income.

Total Monthly Employment Income (A) Please enter valid data.

Total Monthly Value of Other Income (B) Please enter valid data.

Other Services You Currently Use (check all that apply) Food Bank Subsidized School Lunches Saint Vincent de Paul Medicare Medicaid Utility Assistance West Seattle Help Line Other(s)

List any other services you currently use. Please enter valid data.

Total Monthly Value of Services Used (C) Please enter valid data.

Total Monthly Income (A+B+C) Please enter valid data.

REASON FOR REQUEST

Amount Requesting Please enter valid data.

Is this the first time you've requested a Shoulder to Shoulder grant? Yes No

Please explain what has happened and why you are requesting this grant.

Please list any and all other community resources you have requested and received.

Please list any assistance you've requested and/or received from Shoulder to Shoulder, or Holy Rosary Church, including dates, amounts, and detail.

What are the steps you are taking towards self-sufficiency?

Additional Comments

PARISHIONER STATUS

Are you a registered Holy Rosary parishioner? Yes No

Check all that apply. I attend mass regularly. I am committed to personal spiritual growth. I volunteer to give my time and talent. I participate in sacrificial giving.

REQUIRED DOCUMENTATION

Submit the following documentation with your application.

A current paystub for all household members currently employed.
Your most recent 1040 Federal Tax Return.
A copy of your current bank statement, including savings account.

Documents may be submitted electronically (email [email protected]) or through US Mail (Holy Rosary Church, Attn: Shoulder to Shoulder, 4139 42 nd Ave SW, Seattle, WA. 98116) Your application will not begin to be processed until these documents are received.

The identity and personal information of all applicants and their families will be held in strict confidence. Information about you and/or your family will not be shared with the Parish community unless specific written permission has been granted.

All information provided in this application is accurate, comprehensive, and complete.

I Agree Please select this field.

Holy Rosary Catholic Church

West Seattle