Because stability can’t wait.

Start here to request urgent support for rent, utilities, or both.
This form helps us understand your situation so we can respond quickly and fairly. Please complete all required fields — incomplete applications will not be considered. If selected, you’ll be contacted for a virtual intake interview. Your information remains confidential and is used solely to determine eligibility for assistance.

Emergency Assistance Application Form

Section 1: Basic Applicant Info

Full Name *

Email *

Phone *

Address

Street Address

City

State

Country

Postal code

Are you the leaseholder or account holder at this address?

Section 2: Type of Assistance Requested

What type of assistance are you requesting?

Section 3: Utility Assistance Details (if selected)

Which utility provider(s) do you need help with?

Is the account in your name at your current address?

Yes

No

Have you received a past-due or disconnect notice?

Yes

No

Section 4: Rental Assistance Details (if selected)

Is your name listed on the lease agreement for your current residence?

Yes

No

Are you currently facing eviction or behind on rent?

Yes

No

Section 5: Household & Financial Info

How many people live in your household?

Are there children under 18 living in your home?

Yes

No

Current monthly household income (before taxes):

What is the source of your income? (select all that apply)

Briefly explain the reason for this emergency request.

Section 6: Next Steps

If selected, are you available for a virtual intake interview?

Yes

No

Preferred method of contact:

Text

Phone call

Email

Final Confirmation

I confirm that all information provided is accurate to the best of my knowledge. I understand that if selected, I will be contacted by InspireU Foundation for a virtual interview to complete the intake process.

I also understand that the completion of the application doesn’t guarantee assistance.

If selected for assistance, I understand that I have 72 hours to submit the required documentation. If I don’t send in the documentation, my spot will be forfeited.

Because stability can’t wait.

Emergency Assistance Application Form

© Copyright InspireU Foundation 2025 All rights reserved.Privacy Policy | Terms & Conditions

© Copyright InspireU Foundation 2025 All rights reserved.
Privacy Policy | Terms & Conditions