InTake Form

Completing this form and, others, does not imply acceptance of loan request, nor does it imply that funds are available for assistance. The information gathered on this form will help us to determine your eligibility in the event that funds become available. All information is kept confidential and is not shared with other people, organizations, or companies. The information you provide is confidential and will not be released without your permissions. Information is used for evaluation purposes and is required by our funders/sponsors.