Name Change Financial Aid Application - Eastern PA Transgender Equity Project

Is this an application for you or for your minor child? If for a minor child please complete the application using your personal information and then provide details about your child in the "Other Information" section.*

Myself
Minor Child

What type of assistance are you seeking?*

Financial Aid
Mentoring
Both

Personal Information

Current Legal Name*

First Middle Last

Chosen Name*

First Middle Last

Pronouns*

What is your gender identity?*

Transgender Woman
Transgender Man
Nonbinary
Two Spirit
Cisgender Woman/Man
Other

Address*

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

County of Residence*

Email*

Phone*

What is Your Age?*

What is Your Ethnicity?*

Asian
Black / African American
Caucasian / White
Hispanic / LatinX
Native American
Pacific Islander
Mixed
Other

Financial Information

Are You Currently Employed*

Occupation*

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

If employed, what is your PERSONAL monthly income (after taxes) from work?*

What is your PERSONAL monthly income from other sources? Please include: contract work, rents, trusts, government assistance:.*

What is the amount of your current monthly PERSONAL expenses (food, housing, childcare, utilities,transportation, medical, etc.)?*

What is your monthly HOUSEHOLD income from all sources including: jobs, contract work, rents, trusts, government assistance:. This should be the total for all household members.*

What is the amount of your current monthly HOUSEHOLD expenses (food, housing, childcare, utilities,transportation, medical, etc.)? This should be the total expenses for all members of the household.*

Are you receiving or qualify for any of the following assistance programs*

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

Are you able to provide documentation of sources of income or financial assistance (e.g. W-2, 1099, etc.) This may include copies or screenshots.*

Yes
No

Are you able to provide copies/screenshots of your key expenses (rent, utilities, etc.)?*

Yes
No

Health Care Provider Certifications

Have you received letters from your Healthcare Provider that certify you have undergone appropriate treatment for gender transition?*

Yes
No

Can you provide a copy of Health Care Provider certifications if requested?*

Yes
No

Other Information

How did you learn about EPTEP's Financial Grant Program?*

If you selected "other" or "from agency" above, please describe how you learned about this program.

Other Information: 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.*

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?

Affirmation

Would you like to receive the Eastern PA Trans Equity Project / LV Renaissance 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 – Name Change

Personal Information

Financial Information

Health Care Provider Certifications

Other Information

Affirmation