Eastern PA Trans Equity Project

Chosen Name*

First Last

Legal Name*

First Last

Pronouns

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Email Address*

Phone Number*

Please describe why you are applying for assistance and what assistance you require. Please note: we only are able provide assistance for utilities, transportation, or affirming medications. Please include the dollar amount you require, the vendor, and any other specifics that will help us to make a decision.

If you need a bus pass, Eastern PA Trans Equity Project can provide bus passes to qualified applicants. What bus system do you use?

Lehigh Valley – LANTA
Montgomery County – Ride On
Monroe County – Pocono Pony
Luzerne County – LCTA
Lackawanna County – COLTS
Berks County - BARTA

Ethnicity or Race*

Asian
Black/African American
Caucasian/White
LatinX/Hispanic
Native American
Pacific Islander
Other
Prefer not to say

Age*

Are you currently employed?*

Yes
No

If employed, who is your employer?

How many people reside in your household?*

What is the amount of your current monthly household income (for all members of the household)?*

What are the current monthly expenses for the household (for all members of the household) in dollars?*

Are you able to provide documentation of your income or expenses if requested (screen shots/documents)*

Yes
No

Are you enrolled in any of the following assistance programs?*

SSI
SSDI
TANF / Heating Assistance
SNAP / Food Stamps
CHIP or Medicaid
Housing Choice Voucher Program
None

How did you learn about this Program?*

If you chose "Other" or "Referred by an Agency" please describe:

In 2-3 sentences, please describe your shelter, food, clothing, and health needs at this current stage of your life

In 3-5 sentences, please explain the history and current of your Mental, Physical, and Substance health (NOTE: Please respond as little or as much as you feel is comfortable to you. Your answers will not disqualify you automatically. They will help us to make a more thoughtful decision):

In 2-3 sentences, please explain any information about your history or current experiences with homelessness and the shelter system (NOTE: Please respond as little or as much as you feel is comfortable to you. Your answers will not disqualify you automatically. They will help us to make a more thoughtful decision)

Have you ever applied for a grant from Eastern PA Trans Equity Project in the past?*

Yes
No

If you answered "yes," what type of grant did you apply for?

Is there any other information the Grant Committee needs to make a decision?

Would you like to receive our monthly newsletter and other updates?

Yes
No

I affirm that I am a transgender/gender diverse person or the parent of a transgender child. I furthermore affirm that the information in this application is true and accurate. I agree that any funds or gift cards I receive will be used exclusively for food and sustenance for me or my family*

Click to affirm

Mutual Aid Assistance

Mutual Aid Grant Application