Form

Welcome to the 2012 Empty Stocking Fund Application!
The process for applying has changed from the previous years, please read on and follow the instructions. To be eligible for assistance, you must live in Santa Fe County, Rio Arriba County or San Miguel County in the state of New Mexico.

*The last day to apply is Dec. 7th, 2012. No late applications will be accepted.

Step 1, please fill out and answer the following questions as acccurately as possible.

Step 2, your application will be reviewed, and qualified candidates will be contacted to schedule in-person interviews.

No phone calls please.

Thanks and good luck!
Did you receive assistance from the Empty Stocking Fund last year (2011)?*

No, I did not receive assistance last year I'm not sure, or I don't remember I received assistance last year
Do you wish to continue?*

Address*

Mailing Address (only if different)

Assistance and Amount Requested:

Reason for request
Please describe the crisis or emergency that requires financial assistance. Please state your specific needs.*
Click to edit
Click to edit
Do you have children or other household members?*

Yes No
Name 1
First Name Last Name
Birth Date 1
Month Day Year
Name 2
First Name Last Name
Birth Date 2
Month Day Year
Name 3
First Name Last Name
Birth Date 3
Month Day Year
Name 4
First Name Last Name
Birth Date 4
Month Day Year
Name 5
First Name Last Name
Birth Date 5
Month Day Year

Enter Monthly Income below:

	Work Income Amount	TANF	SS or SSI	Food Stamps	Other Income
Applicant
Spouse/Partner

Enter Monthly Expenses Below:

If You Are Asking For Utility Assistance please answer these questions:*

	Yes	No
Are you receiving energy assistance?
Are you signed up for the budget billing plan?
Have you had your home audited for energy efficiency?

If You Are Asking for Rent or Mortgage Assistance:
Is your rent currently subsidized?*

Yes No
How many months are you behind in your rent/mortgage payments?
Signature and Authorization:
Please note that funds are limited. While every attempt is made to assist as many qualified individuals and families possible, submitting an application does not guarantee that you will receive assistance.

All applications are the property of the Empty Stocking Fund.

By digitally signing this application, I understand that I may be contacted by a reporter with the Santa Fe New Mexican to obtain information for a possible newspaper story. I also understand that use of my story does not guarantee assistance from the Empty Stocking Fund and that not all stories will be printed in the paper.

I give my authorization for you to release personal and financial information concerning my application to the Empty Stocking Fund Committee.

I give my authorization for the Empty Stocking Fund to verify my request with my landlord, creditors and other agencies as needed.

I agree that all the information I have provided is true. Any falsehoods discovered could render the application void. Any financial assistance received from the Empty Stocking Fund fraudulently may result in legal action.
....*

I've read and accept the terms above.
Today's Date*
/ Month / Day Year
If you have an email address enter it below to receive a confirmation of your submission:
Should be Empty:

Welcome to the 2012 Empty Stocking Fund Application!