Grants of Hope Application

Are You Safe? If "No", please call the National hotline 1800-799-Safe

Yes No

Are you still with your Abuser? If "Yes", please call the National hotline 1800-799-Safe. The criteria of this program requires clients to be away from their abuser for a minimum of 6-months before applying for Grants of Hope Funding.

Yes No

What County do you reside in?

Prefered Method of Contact

Phone Email

Please list all household members and their date of birth.

Are you employed?

Yes No

Employment: If "Yes", where are you currently employed. If "No", please briefly explain describe why?

Are you receiving unemployment?

Yes No

Unemployment: If "Yes", when did it start and when does it end?

What are your skills, education level, and training?

Do you have disability that prevents you from working?

Yes No

Disability: If "Yes", are you filing through a attorney or by yourself?

Do you have an open case with any sort of "child services"?

Yes No

Child Services: If "Yes", please provide the case workers name and phone numbers.

Child Services: If "Yes", please briefly describe why and when they became involved?

Does your child have a Guardian ad Litem?

Yes No

Do you receive Food Stamps?

Yes No

As requirement of the program if "Yes" to Food Stamps will you be able to provide proof of food stamps? Yes or No

Do you receive WIC (Women,Infants,and Children)

Yes No

Do you receive Cash Assistance from the state?

Yes No

Cash Assistance: If "Yes", how much per month?

As requirement of the program if "Yes" to Cash Assistance will you be able to provide proof from state? Yes or No

Do you receive Medical Assistance for you or your children?

Yes No

As requriement to the program if "Yes" to Medical Assistance can you provide proof from the state? Yes or No

Do you receive rent assistance?

Yes No

Rent Assistance If "Yes", when did you begin receiving it?

As requirement of the program if "Yes" to Rent Assistance can provide proof? Yes or No

What is your Abusers name?

What is your Abuser date of birth?

When did you leave your abuser?

What City ,State, and Country or Counties did you live in when you were with your abuser?

Do you have an order of protection?

Yes No

Order of Protection if "No", please briefly describe why?

Do you and your abuser have children together?

Yes No

Have you filed for child support?

Yes No

Does your abuser have visitation rights?

Yes No

Are you currently in a unhealthy relationship?

Yes No

Abuser: Is he/she currently in jail?

Yes No

Abuser: If "Yes" for what and how long?

What type of financial assistance are you requesting from Break The Silence against Domestic Violence? *

Please briefly describe the circumstances surrounding your request for assistance.

Have you ever used illegal drugs?

Yes No

If offered assistance, would you submit to a drug screening?

Yes No

Have you ever been arrested or plead guilty to a crime?

Yes No

Crime If "Yes", please explain.

If Break the Silence is able to provide you with assistance, what are your plans to remain stable in the future?

If Break the Silence is able to provide you with assistance , are you able to complete the online training required to be a part of our Grants of Hope Program? Yes or No

If Break the Silence is able to provide you with assistance, are you willing to work closely with one of our advocates for the 6month-1year to ensure your success?Yes or No

How did you hear about BTSADV?

Friend or Family Social Media Internet Search Television other

As requirement of the program are you able to provide 3 months of Bank statements? Yes or No

As requirement of the program are able to provide 2 pay stubs? Yes or No

Do you give Break The Silence against Domestic Violence permission to speak to any and all case workers and professionals you are working with for purpose of Grants of Hope screening? Yes or No

I give full permission to Break The Silence against Domestic Violence to use my story, photo,and testimonial for any and all purpose deemed necessary for an indefinite purpose. Yes or No

Please sign below that you have read and fully understand the questions in this application. You also certify ,that all of the answers given are true to the best of your knowledge. You give Break the Silence against Domestic Violence permission to conduct a criminal background check.

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support@salsalabs.com | (202) 787-3000