Mutual Aid Assistance - Eastern PA Transgender 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*

County of Residence*

Type of assistance you are requesting

Utility Bill (note: you will be required to forward a copy of your bill))
Car repair (note: you will be required to provide a written estimate)
Bus Pass
Medication (note: we will require a copy of your prescription)

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.*

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 / Welfare
LiHeap / Heating or Utility Assistance
SNAP / Food Stamps
CHIP or Medicaid
Housing Choice Voucher Program
None

How did you learn about this Program?*

If you have CashApp or Venmo please provide that information here so that we can expedite payment if approved.

If you chose "Other" or "Referred by an Agency" please provide the name of the agency or person referring you:

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

Please provide detailed information about your background as a transgender person.*

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

Are you a transgender person or the parent of a transgender child?*

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 Grant Application