Eastern PA Trans 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*

Email*

What is your age?*

Race*

What Type of prosthetic or garment are you seeking?*

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 your MONTHLY income from all sources including: jobs, contract work, rents, trusts, government assistance:*

What are your current MONTHLY expenses (food, housing, transportation, medical, etc.)?*

Do you qualify for any of the following assistance programs*

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

Please share any other information that will help the Committee to make a decision with regard to granting financial assistance.

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

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

How did you learn about this grant program?

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

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

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.