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Please make certain you have read the STEP LADDER PROCESS OF 10 WAYS WE CAN CAN HELP on our Returning Hope to Returning Citizen page before filling out this Application.
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Please provide what emergency need or needs you are currently experiencing (for example: clothing, security deposit or first month’s rent, utility bills, tools/equipment for my current job, back rent, furniture, home furnishings etc.)
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If you know, please provide the specific cost of this emergency assistance needed from Here to Help. If you’re not sure what amount you need put “Not Certain."
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| Name |
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| Phone number |
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| Are you able to text from your phone? |
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| Email address |
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(You will need to create an email if you don’t have
one so we can communicate with you further.) |
| Street address |
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| City |
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| State |
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MI |
| Zip |
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| County |
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| Moving? |
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(If you will soon be moving, please provide the city you are moving to) |
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| Date of Birth |
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Who referred you to Here to Help or how did you learn of our ability to assist?
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If you have children, please list their ages
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When were you released from prison?
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Are you working with a parole agent? If so, what is his/her name and phone number and email address if you have that?
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What has your parole agent assisted you with or advised you at this time?
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Is any other individual or other agency or organization assisting you with your reentry? If so, please provide his/her name and phone number and what their job is and what they are doing to help you.
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Please explain your current living situation. Are you living in a group home/transitional house or with family members or have have you rented your own apartment?
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When did you move into your current living situation?
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If you are not living in your own place what are your plans as far as your future living situation and is anyone helping you find a place?
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Do you have any income at the present time? If so, please provide the sources of all your monthly income. For example, wages or disability assistance or Social Security or food assistance etc. If you receive rent assistance, please list that as well.
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If no income at present, please answer if you anticipate receiving income in the future and from what sources.
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If you have an income now, please provide the amount of your net income (after taxes, deductions, garnishments etc.) you earn per month whether it be from wages or disability or Social Security etc. Again, this is your take home pay after all deductions are made from your source of income.
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If you are working, please provide the name of where you are working, the address, when you began working there, how many hours you work per week and your hourly pay or monthly salary.
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If you are NOT working, please answer what you are currently doing or planning to do to obtain employment or job training and who, if anyone, may be assisting you. This is a very important answer so please be specific.
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If you are disabled and cannot work, please answer whether you have applied for benefits and the status of that request if any.
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If you currently have monthly bills, please list the names of your monthly bills and expenses and the specific amounts for of ALL of these monthly costs. For example: rent, food, phone, heat, gas, water, electricity, cable, day care, credit card bills, medical costs, transportation costs, any loans including car loan payments, car insurance, toiletries, average monthly clothing costs and ANYTHING else).
List the name of each expense AND the amount for each expense per month.
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Clothing: If you are in need of help with clothing, please list what specific items you need and including any specific work related clothing.
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Home Furnishings: If you are in need of help with home furnishings, please list what what you need (for example, pots and pans, silverware, dishes, glasses, sheets/pillows, towels, etc.).
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Furniture: If you are in need of help with furniture, please list what furniture you currently own and what you need.
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Move In Costs: If you have found your own apartment or home and need help with security deposit or first month’s rent, please state how much you need.
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Used Cars (for full time employees): If you’ve been able to obtain a job working 35 or more hours per week and you're in need of transportation to get to/from work, then please explain your current situation including how you are now getting to work.
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Car Repairs: Please list all of the repairs that are required, the car’s year, mileage, make and model. Please also answer when you bought the car.
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Please list which of the following you need assistance with as we can provide information to help you:
Obtaining a Phone
Obtaining governmental documents (State ID or Driver's License or Social Security card etc.)
Employment and Job Training
Finding Housing
Public Benefits (for example: food benefits, disability payments etc.)
Counseling
Substance Abuse Treatment
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