Financial Assistance Form

At QuietWaters, we never want finances to be the reason why someone cannot get the counseling help they are looking for. Through the fundraising efforts of QuietWaters and the generosity of donors, financial assistance is available to those who qualify. Please complete the application below to submit your request.

"*" indicates required fields

Your Information

Name*

First Last

Email*

Enter Email Confirm Email

Phone*

Secondary Phone

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are you married?

Yes

Spouse's Name*

First Last

Do you have children living at home?

Yes

What are their ages?

Church/Organization Information

Name of Your Church/Organization

Denomination

Financial Assistance Information

Total amount of assistance requesting?

What are the reasons for requesting financial assistance?

Please note any extenuating financial circumstances (medical, job loss, unusual expenses, etc.)

Please list other sources of assistance that you have sought.

(church, organization, denomination, friends, etc.)

Annual Gross Income

Employment

Employer

Income

Spouse's Employment

Employer

Income

Other Source of Income

Source

Amount

Assets

Bank/Credit Union

Trust Funds/Stocks/Bonds

Life Insurance

Automobile

Personal Property

Other Assets

Anything else you can tell us that might be helpful?