Gender Affirming Garment/Prosthetic Grant Application - Eastern PA Transgender Equity Project

Personal Information

Current Legal Name*

First Middle Last

Chosen Name*

First Middle Last

Pronouns*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

County of residence

Email*

What is your age?*

Race*

What Type of prosthetic or garment are you seeking?*

Binder
Packer or STP
Gaff
Breast Forms
Gender-specific clothing (male outerwear)
Gender-specific clothing (female outerwear)

Financial Information

Are You Currently Employed*

Occupation*

If employed, how many hours per week do you work?

If employed, what is your income from work?

What is the amounty of your MONTHLY household income from all sources including: jobs, contract work, rents, trusts, government assistance? Note: this is for all members of the household.:*

What is the amount of your current MONTHLY household expenses (food, housing, transportation, medical, etc.)? Note: this is for all members of the household.:*

Do you qualify for any of the following assistance programs*

SSI
SSDI
TANF / Welfare
LiHeap / Utility or Heating Assistance
SNAP/Food Stamps
Medicaid or CHIP
Housing Choice Voucher Program
None of the above

Are you able to provide documentation of income (e.g. W-2, 1099, etc.?)*

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

Please share any other information that will help the Committee to make a decision with regard to granting financial assistance. This can include information with regard to your current financial situation, gender transition or life as a person of trans experience.*

Prior Applications

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

Yes
No

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

How did you learn about this grant program?

Bradbury-Sullivan LGBT Center
Valley Youth House
Other Agency (specify below)
Referral from Friend
Facebook
Instagram
Other Social Media
Other (specify below)

If you chose "other agency" or "other" above – please specify

Affirmation

Would you like to receive the Eastern PA Trans Equity Project/LV Renaissance Monthly Newsletter

Yes
No

I affirm that the information in this application is true and accurate according to my knowledge.*

I affirm that the information in this application is true and accurate according to my knowledge.

Financial Aid Application – Gender Affirming Garment/Prosthetic

Personal Information

Financial Information

Prior Applications

Affirmation