NSPIRE ME 365

COMMUNITY GIVEBACK ASSISTANCE APPLICATION

Gas Cards | Tee's Catering Gift Certificates | Electric Bill Assistance

Eligibility Requirements

Acknowledge all

Applicant must be 18 years of age or older.

Applicant must live within Nspire Me 365's designated service area.

Only one application may be submitted per household.

Applicant must have a current need for assistance with food, gas/transportation, or electricity.

For electric bill assistance, a current utility bill may be required. Priority may be given to households with a past- due balance, disconnect notice, or disconnected service.

Assistance is limited and submitting an application does not guarantee an award.

Selected applicants may be asked to provide identification or other documentation needed to verify eligibility.

There is no fee to apply.

Applicant Information

First name

Last name

Phone

Address

Number of adults in household:

Number of children:

Have you received assistance from Nspire Me 365 within the past 12 months?

Yes

Assistance Requested

Check all that apply:

Gas Card

Option Tee's Catering Gift Certificate

Electric Bill Assistance

I am open to whichever assistance is available

Current Household Need

Which statement(s) best describe your household's current situation? Check all that apply.

I am having difficulty purchasing food.

I am having difficulty affording transportation/gas for work, school, medical appointments, or essential errands.

I am behind on my electric bill.

My electricity is currently disconnected.

I have received a disconnect notice.

An unexpected financial hardship has affected my household.

Other

Tell Us About Your Need

Please briefly tell us about your current need and how this assistance would help your household.

Please do not include Social Security numbers, utility account numbers, bank information, or other sensitive information.

Applicant Certification

I certify that the information provided in this application is true and accurate to the best of my knowledge. I understand that Nspire Me 365 Community Giveback assistance is available while funds and resources last and that submission of an application does not guarantee assistance. Applications will be reviewed using consistent eligibility and need criteria. Selected applicants will be contacted directly. Providing false or misleading information may result in disqualification.

Applicant Signature:

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Signature Date:

Privacy Notice

Information submitted will be used solely for determining eligibility for this community assistance program and administering awarded assistance. Nspire Me 365 will not request Social Security numbers or bank account information through this application.

Photo & Media Information

Nspire Me 365 may take photographs and/or video during the distribution or community giveback for nonprofit outreach, community impact reporting, social media, website content, promotional materials, and future program awareness. Participation in photographs is optional and will not affect an applicant's eligibility for assistance.

Photo/Media Preference

YES - I give Nspire Me 365 permission to photograph and/or record me and use the images/video for nonprofit promotional and community outreach purposes

NO - I do not give permission for my image or video to be used.

Option I am completing this application for a household that includes a minor. I understand that a parent/legal guardian's permission is required before an identifiable image of a minor is intentionally used.

Important: Choosing NO to photos or video will not reduce your chances of receiving assistance.

Parent/Guardian Signature (if applicable):

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Parent/Guardian Name (if applicable):

Date Signed

NSPIRE ME 365

COMMUNITY GIVEBACK ASSISTANCE APPLICATION

Gas Cards | Tee's Catering Gift Certificates | Electric Bill Assistance

Eligibility Requirements

Acknowledge all

Applicant must be 18 years of age or older.

Applicant must live within Nspire Me 365's designated service area.

Only one application may be submitted per household.

Applicant must have a current need for assistance with food, gas/transportation, or electricity.

For electric bill assistance, a current utility bill may be required. Priority may be given to households with a past- due balance, disconnect notice, or disconnected service.

Assistance is limited and submitting an application does not guarantee an award.

Selected applicants may be asked to provide identification or other documentation needed to verify eligibility.

There is no fee to apply.

Applicant Information

Number of adults in household:

Have you received assistance from Nspire Me 365 within the past 12 months?

Yes

Assistance Requested

Check all that apply:

Gas Card

Option Tee's Catering Gift Certificate

Electric Bill Assistance

I am open to whichever assistance is available

Current Household Need

Which statement(s) best describe your household's current situation? Check all that apply.

I am having difficulty purchasing food.

I am having difficulty affording transportation/gas for work, school, medical appointments, or essential errands.

I am behind on my electric bill.

My electricity is currently disconnected.

I have received a disconnect notice.

An unexpected financial hardship has affected my household.

Other

Tell Us About Your Need

Please briefly tell us about your current need and how this assistance would help your household.

Please do not include Social Security numbers, utility account numbers, bank information, or other sensitive information.

Applicant Certification

Applicant Signature:

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Photo & Media Information

Photo/Media Preference

YES - I give Nspire Me 365 permission to photograph and/or record me and use the images/video for nonprofit promotional and community outreach purposes

NO - I do not give permission for my image or video to be used.

Important: Choosing NO to photos or video will not reduce your chances of receiving assistance.

Parent/Guardian Signature (if applicable):

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Parent/Guardian Name (if applicable):