RCM - Ethaar Financial Aid Request

Welcome to the Financial Aid Application Form. Please provide accurate and complete details to facilitate the evaluation process. Your privacy is important to us, and all information submitted will be handled with confidentiality.

Contact Information

Full Name *

Cell Phone *

Email *

Existing Client

Has your family received services from Ethaar before? *

YesNo, this is my first time

Employment

Employment Status *

UnemployedFull Time EmployedPart Time Employed

If unemployed, have you applied for the Georgia Department of Labor? *

YesNoNot applicable (employed)

If employed, what is your current income? (total monthly household income)

Housing

Describe your current housing situation *

Monthly rent or mortgage payment *

Are you experiencing any housing-related difficulties or threats of eviction? *

YesNo

Financial Aid Request

Financial Aid Request Length and Amount *

One Lump SumRecurring

If recurring - duration (weeks or months)?

Reason for request *

Other reason (optional)

Emergency & Health Needs

Are you currently facing urgent financial needs or emergencies? *

Is there a health issue/concern - injury or illness? *

Previous Assistance & Assets

Have you received SNAP benefits (Food stamps)? *

YesNo

Do you own significant assets (property, vehicles, savings)? *

Does the family own a vehicle? *

YesNo

Have you received a tax refund? If yes, how much and when? *

When did you last receive financial support from any organization or individual? *

Have you applied for financial assistance elsewhere recently? *

Monthly Expenses

List all monthly expenses: Rent, Power Bill, Gas Bill, Water Bill, Internet/Phone, and any other.

Monthly Expenses *

Would you like to receive any of the following free services? *

Financial LiteracyTherapistEmployment SpecialistReligious Counseling (Meeting with the Imam)

Required Documents

Please upload your bank statements (up to 3 months), recent pay stubs, and a valid form of identification. Combine into a single PDF if possible.

Upload Documents*

PDF, JPG, or PNG — max 10MB.

Consent & Agreement

The following legal text is provided in English only for accuracy and will not be translated.

Disclaimer The applicant acknowledges that Ethaar and RCM may require additional documentation or information to verify the application details. By submitting this application, the applicant consents to such verification and agrees to cooperate fully with any requests for additional information. Ethaar and RCM are committed to a fair and transparent evaluation process for all financial aid applications. However, decisions regarding the allocation of financial aid are final and are not subject to appeal. Authorization By filling and submitting this form, I hereby authorize Ethaar, along with its agents and employees, to obtain, share, and discuss my case information with other non-profit organizations, individuals, and resettlement agencies that may assist with my requirements. The types of information that may be shared include, but are not limited to, Entry/Exit Dates, Psychological Evaluations, Case Summaries, History of Abuse, Details on Children including their names, Assessments, Legal Documents, Substance Abuse records, and any other relevant information. I understand and acknowledge that my consent for the above is granted indefinitely. However, I retain the right to withdraw this consent at any point in writing.

I understand and acknowledge the disclaimer above. *

The following legal text is provided in English only for accuracy and will not be translated.

I grant Ethaar and RCM permission to exchange case-related information as necessary. *

Client Agreement

The following legal text is provided in English only for accuracy and will not be translated.

• I agree to provide any relevant documentation supporting financial claims. • I certify that the above statements and information are accurate to my knowledge. • I consent to use this information to determine my eligibility for financial assistance. • The application may only be accepted once the information is verified. • Meeting the outlined criteria does not automatically ensure approval or guarantee financial assistance.

I hereby agree to the Client Terms and Conditions. *