EREZ FUND APPLICATION FOR ASSISTANCE
NOTE
CURRENTLY WE HAVE OVER 120 APPLICATIONS ON FILE.
APPLICATIONS ARE FILLED PER QUALIFYING AND ON A 'FIRST COME, FIRST SERVED' BASIS, AS WE AWAIT DONATIONS.
PLEASE CHECK BACK FOR UPDATES.
EFFECTIVE OCTOBER 25, 2012
ALL APPLICANTS MUST USE THIS FORM. FORMS FROM
PREVIOUS YEARS WILL NOT BE ACCEPTED DUE TO IMPORTANT MODIFICATIONS.
Emergency assistance funds are distributed on a first-come basis. Eligibility and assistance donations are a one time payment based upon the number of people in your home, income of everyone in your home, type and cost of heating and where you live. If you are eligible, the payment is made to your supplier. The EREZ Fund currently supports requests having to do with weather related crises.
PLEASE PRINT
Name: ______________________________________________________
Date of birth: ______________________ Age: ___________
Do you have fuel now? ____ Number of people living in the home: ______
Ages of people living in the home: _________________________________
Is anyone over the age of 65? _________
Nature of request for assistance: ___________________________________
RESIDENCE
Delivery Address: ______________________________________________
City: __________________________________________________________
Your Telephone number: _________________________________________
Name of Reservation, Agency or Territory: ___________________________
Type of heating fuel (circle one): wood / propane / electric
Vendor Company Address: _______________________________________
Vendor Company Phone Number: _________________________________
Account Number: _______________________________________________
Age of home: ___________
INCOME INFORMATION
Monthly household income: $______________
Source of Income: _______________________________________________
REFERRAL
Where did you hear about the Whisper n Thunder EREZ Fund?
_______________________________________________________________
DISCLAIMER
Whisper n Thunder assumes no liability for negligent use by receiver or any malfunction of wood, propane, or electric heating units that results in property or personal damage of any nature at any level. By signing this application you acknowledge that you have read and accept this disclaimer.
AUTHORIZATION
Signed: ________________________________________________________
Date: __________________________________________________________
Please mail to:
Whisper n Thunder Inc.
c/o Rebecca Balog, EREZ Chair
PO Box 10891
Glendale, AZ 85318
