Lazarus Fund Intake Form
IMPORTANT NOTE: The Lazarus Fund grants are awarded for rent, mortgage payments, security deposits, and utilities to residents of Allegheny County ONLY.
Date of Application/Interview
*
-
Month
-
Day
Year
Date
Sponsoring Congregation
*
Interviewer
*
First Name
Last Name
Interviewer Phone Number
*
-
Area Code
Phone Number
Applicant Information
Applicant Name
*
First Name
Last Name
Applicant Date of Birth
*
-
Month
-
Day
Year
Date
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of Years at Current Address
*
Own/Rent
*
Own
Rent
Primary Phone Number
*
-
Area Code
Phone Number
Is it okay to text this number?
*
Yes
No
Alternate Phone Number
-
Area Code
Phone Number
Is it okay to text this number?
Yes
No
How did the applicant hear about the Lazarus Fund?
Has the applicant applied for help through the Lazarus Fund before?
*
Yes
No
If yes, has it been within the last three years?
Yes
No
Does the applicant have an additional source of support?
*
Yes
No
If yes, please explain.
Has the applicant contacted his/her creditor(s)?
*
Yes
No
Applicant Story
Provide a short description explaining the circumstances that caused the need of the applicant.
*
Is there anything else that should be shared with the Lazarus Fund ministry Team?
*
Applicant Family Information
Name of Partner
First Name
Last Name
Partner Date of Birth
-
Month
-
Day
Year
Date
Dependent #1 Name
First Name
Last Name
Dependent #1 Date of Birth
-
Month
-
Day
Year
Date
Dependent #2 Name
First Name
Last Name
Dependent #2 Date of Birth
-
Month
-
Day
Year
Date
Dependent #3 Name
First Name
Last Name
Dependent #3 Date of Birth
-
Month
-
Day
Year
Date
Dependent #4 Name
First Name
Last Name
Dependent #4 Date of Birth
-
Month
-
Day
Year
Date
Applicant Financial Snapshot
Reason for Grant
*
Rent
Utilities
How much money is the applicant applying for from the Lazarus Fund?
*
Payee Name
*
Payee Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Memo Line
Payee Name
Payee Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Memo Line
Income (not required but desired)
Expenses (not required but desired information)
Debt (not required but desired information)
Submit
Print Form
Should be Empty: