Criteria Fact Sheet

The GiveBack Foundation, Inc.
P. O. Box 535
Allentown, N.J. 08501
www.thegivebackfoundation.com
Criteria Fact Sheet

NAME(S):
ADDRESS:
PHONE: ____________________________________ FAX: __________________________________________
E-MAIL: ____________________________________________________________________________________
The purpose of the Foundation is that of a non-profit organization operating in the local region consisting of the New
Jersey Counties of Monmouth, Burlington, Ocean, Middlesex and Mercer to help people in need with life-altering
circumstances.
Please answer the following questions. Either you as the recipient or someone who is nominating an individual
should complete all sections in its entirety. Use additional pages as needed.
1. How did you hear about us and by whom? _____________________________________________________
________________________________________________________________________________________
2. The Foundations purpose is to help with life-altering circumstances. Explain how your situation fits this
purpose?________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
3. Describe in detail how the Foundations assistance could help you. (May write and attach separate letter, not
to exceed two pages.)______________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
4. Are you presently employed or do you have any prospects? ________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
5. Is your request based on financial need? YES_____NO_____.
If yes, please provide specifics details of your financial situation. Use the attached Income/Asset and Debt
forms. If no, what specifically could The Give Back Foundation do for you? ________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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6. How many people in your household? ___________ List all names and ages below.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
7. Is your situation temporary? How long do you think it will take to remedy without assistance? ___________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
8. What are you currently doing to help yourself as a short term solution? ______________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
9. What other sources such as churches, foundations or social service agencies have you reached out to? Who
and how have they assisted you? _____________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
10. We will conduct an interview to review your situation. When would be the best time for the Foundation to
personally meet with you to further discuss your request? _________________________________________
________________________________________________________________________________________
11. Please list at least three personal, medical, or business references:
Name: ______________________________________ Phone: _______________________________
Address: _________________________________________________________________________
Relationship: ______________________________________________________________________
Name: ______________________________________ Phone: _______________________________
Address: _________________________________________________________________________
Relationship: ______________________________________________________________________
Name: ______________________________________ Phone: _______________________________
Address: _________________________________________________________________________
Relationship: ______________________________________________________________________
12. Please list any other information you feel may be helpful to us as we review your situation._______________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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________________________________________________________________________________________
By signing this application I certify that the information is true and correct. I authorize The Give Back Foundation,
Inc. to contact any references or businesses listed.
Printed Name: _________________________________________________________________________
Signature:
Date:
Please mail completed form to:

The GiveBack Foundation, Inc.
P. O. Box 535
Allentown, N.J. 08501
Income and Assets Information:

Income/Asset Source,
Indicate N/A if none
Salary 1 (employer name_______________)
Salary 2 (employer name_______________)
Social Security
Pension
Annuity
Investments
Other Interest Income
Alimony
Child Support
Disability Benefits
Income Amount
List Weekly,
Monthly or
Annual
Balance
Cash Value
Other Income (Source__________________) $

Other Income (Source__________________) $
Assets
Checking Account
Savings Account
IRA Accounts
401K (can borrow against? Circle Y or N)
Life Insurance 1 (borrow against? Y or N)
Life Insurance 2 (borrow against? Y or N)
Other Asset (Source___________________)
Other Asset (Source___________________)
Debt Information:
Creditor Name
(add additional names if needed)
Amount Overdue
(if any)
Monthly Payment
Mortgage or Rent (circle one)
Electric
Gas
Phone
Cell Phone
Cable TV
Computer
Food
Medical
Car Payment
Auto Insurance
Home Owners Insurance
Credit Card 1
Credit Card 2
Credit Card 3
Other Loan (type:___________)
TOTALS OF EACH COLUMN
$___________________ $___________________

Criteria Fact Sheet - The Give Back Foundation

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The GiveBack Foundation, Inc.

Please mail completed form to:

Income and Assets Information:

Salary 2 (employer name_______________)

Other Interest Income

Other Income (Source__________________) $

401K (can borrow against? Circle Y or N)

Life Insurance 1 (borrow against? Y or N)

Life Insurance 2 (borrow against? Y or N)

Other Asset (Source___________________)

Other Asset (Source___________________)

Mortgage or Rent (circle one)

Home Owners Insurance

Other Loan (type:___________)

TOTALS OF EACH COLUMN

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