Chatham Bridging the Gap Application All information will be kept confidential.Not comfortable filling it out online? Print and mail the application. Personal Information Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country What document(s) will you be able to provide as proof of identity and residency in Chatham Borough or Township? * (e.g. State-issued ID, driver's license, current house bill) Phone (home) (###) ### #### Phone (cell) * (###) ### #### Email * How do you prefer that we contact you? * How did you learn about Chatham Bridging the Gap? * Members of household Please list the names and ages (including birth dates and years) of all members of your household Employment Status/Monthly Source of Income of all Household Members Applicant Employer * Salary (past 12 months) * Employment history, salary, and income from other sources (Child Support, Social Security, Disability, etc.) * Other household members who have been employed during the past 5 years Name Employer Salary (past 12 months) Income from other sources (Child Support/Alimony, Social Security, Other) Name Employer Salary (past 12 months) Income from other sources (Child Support/Alimony, Social Security, Other) Total Total Monthly Income * (Documentation for proof of household income for all household members may be required based on funds requested e.g. W2 forms or pay stubs) Expenses Monthly Expenses Rent/Mortgage * Electric * Gas * Water/Sewer * Transportation (Car/Gas/Public) * Car Insurance * Medical Expense * Day Care Credit Cards * Phone/Internet * Child Support Food * Other (please specify) Total Monthly Expenses * (Documentation for proof of household expenses may be required based on funds requested) Please explain in full the expense(s) that you need our help with (proof of expense will be required) * Signature Please indicate agreement with the following: * I covenant not to sue or make any claim against Chatham Bridging the Gap and/or its officers, employees, agents, volunteers and sponsors for injury, death, loss of income or other loss or damage arising out of my participation herein. I agree to hold harmless, defend and indemnify Chatham Bridging the Gap and its officers, employees, agents, volunteers and sponsors for any trespass to property, damage to realty or personal property, wrongful death or personal injury as well as any other claimed loss or damage whatsoever caused by me or my activities in connection with my involvement with Chatham Bridging the Gap. Finally, I agree that the decision of Chatham Bridging the Gap regarding my application is final. I covenant not to sue or make claim against Chatham Bridging the Gap, its officers, employees, agents, volunteers and sponsors for any application determination and/or decision or for any cause of action whatsoever including libel, slander, defamation of character, invasion of privacy, breach of confidentiality or fraud. Yes No I certify that all the information contained in this application is true to the best of my knowledge * Yes No Signature * DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application. Today's Date * MM DD YYYY Thank you for submitting your application. Chatham Bridging the Gap will contact you as soon as possible to meet with you and review.
