Application for Financial Assistance

IMPORTANT NOTICE: Limited Application Intake We are now accepting new financial assistance applications on Mondays & Tuesdays only. This limited schedule allows us to better manage application volume ad provide timely support to those already in progress. Duplicate applications, incomplete applications or applications submitted outside of these two days will not be processed. Please note: Funding is limited, and we are prioritizing verifiable, unexpected emergencies—such as medical crises. Sustainability is a requirement for assistance. Only residents of Broward County for at least 6 months are eligible for assistance. For information on other local assistance programs, please contact First Call for Help of Broward at 211 or (954) 537-0211 for information about other agencies that may be able to assist. Thank you for your understanding.

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Today's Date

MM slash DD slash YYYY

Previous Goodman JFS Contacts

Name

First Last

Sex

Male

Female

Other

Marital Status

Married

Single

Divorced

Widowed

Date of Birth

MM slash DD slash YYYY

Country of Origin

Veteran Status

Yes

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Race

American Indian

Alaska Native

Asian

Black or African American

Native Hawaiian

Other Pacific Islander

White

Declined to answer

Preferred Language

Religion

Citizen of the U.S.

Yes

Number of Years in Broward County(Required)

Address

City

Zip Code

Email(Required)

Phone

List names of each person sharing the household and his/her relationship to you:(Example: Spouse, Mother, Friend, Child)

Person 1

Name 1

Age 1

Date of Birth 1

Occupation 1

Relationship to You 1

Person 2

Name 2

Age 2

Date of Birth 2

Occupation 2

Relationship to You 2

Person 3

Name 3

Age 3

Date of Birth 3

Occupation 3

Relationship to You 3

Person 4

Name 4

Age 4

Date of Birth 4

Occupation 4

Relationship to You 4

Person 5

Name 5

Age 5

Date of Birth 5

Occupation 5

Relationship to You 5

Person 6

Name 6

Age 6

Date of Birth 6

Occupation 6

Relationship to You 6

Highest Level of Education Completed(Required)

Do you have medical insurance?(Required)

Yes

If yes, what insurance?

Current employment

Current Employment(Required)

Full-time

Part-time

Unemployed

Retired

Most Recent Employer

Employer

Job Title

Start Date

End Date

Reason for Leaving

How were you referred to Goodman Jewish Family Services?

Reason for referral

Rent

Mortgage

FPL

Water

Other

Other reason

Please list the names of all other agencies that you have contacted for assistance and explain what type of assistance you received:

Agency 1

Type of Assistance 1

Agency 2

Type of Assistance 2

Agency 3

Type of Assistance 3

Household Income/Expenses

PLEASE FILL IN THE AMOUNT YOU RECEIVE/SPEND PER MONTH FOR EACH OF THE FOLLOWING. ENTER "0" IF NOT APPLICABLE.

INCOME

Employment(Required)

Unemployment(Required)

Social Security(Required)

SNAP(Required)

TANF(Required)

Financial Support(Required)

Child Support/Alimony(Required)

Veteran’s Benefits(Required)

Worker’s Compensation(Required)

Retirement/Pension/Annuities(Required)

Interest/Dividends(Required)

Additional Income Not Listed(Required)

Total Income

EXPENSES. ENTER "0" IF NOT APPLICABLE.

Mortgage/Rent(Required)

HOA/Maintenance(Required)

Electric(Required)

Water/Sewer/Trash(Required)

Property Taxes(Required)

Property Insurance(Required)

Phone/Internet/Cable(Required)

Car Payment/Insurance/Gas(Required)

Transportation(Required)

Child Support/Alimony(Required)

Medical(Required)

Childcare/Tuition(Required)

Total Expenses

Are you living in Section 8 or Section 202 housing?

Yes

If yes, what is your portion of the rent?

PLEASE FILL IN THE CURRENT BALANCE IN EACH OF THE FOLLOWING ASSET ACCOUNTS. To substantiate these figures, please provide us with banks statements(s) and/or monthly brokerage reports for any of the asset accounts listed below.

Checking Account

Stocks/Bonds

Savings Account

Mutual Funds

Acknowledgment(Required)

I understand that financial assistance applications are only accepted on Mondays and Tuesdays and that forms submitted outside of these days or applications that are duplicate or incomplete will not be processed. I also understand that funding is limited, priority is given to verifiable unexpected emergencies such as medical crises and sustainability is a requirement for receiving assistance.

Broward Resident Confirmation(Required)

I have been living in Broward County for at least 6 months.

I declare that the answers to the above questions are true and complete and I hereby give my consent to Goodman Jewish Family Services of Broward County to release or request the above information to community organizations that can provide further assistance. Supportive documents may be requested/required for further evaluation. If information is falsely given, I understand that I may jeopardize my chance of receiving financial assistance.

Signature(Required)