Type of assistance needed *

Chronic Illness - to make medical appointments

Funeral Travel - for immediate family member

Immediate Family Member in Critical Condition

House Fire - total loss

Today's date *

MM

DD

YYYY

Date of appointment or incident *

MM

DD

YYYY

Time of appointment or incident *

Hour

Minute

Second

AM PM

Name of person applying *

Include Maiden Name is applicable

First Name

Last Name

Date of birth *

MM

DD

YYYY

Address *

Include mailing and physical if different

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Fax

(###)

###

####

Power of Attorney or Guardian

No

Yes (include name below)

Name of POA or Guardian

First Name

Last Name

Address of facility

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone number of facility

(###)

###

####

Name of individual impacted if not self

First Name

Last Name

Is this your first EFAL loan this fiscal year? *

Yes

No

Exempt

Are you a veteran? *

If yes, need denial of assistance

Yes

No

Are you a TANF client? *

If yes, need denial of assistance

Yes

No

Are you on Medicaid/DSHS? *

If yes, need denial of assistance if for medical needs

Yes

No

Have you applied for transportation broker? *

If yes, need denial of assistance

Yes

No

Are you a Voc Rehab client? *

If yes, need denial of assistance if for appointment

Yes

No

Are your Per Capitas held from another department? *

Yes

No

Income source *

Please check all that apply.

Employed

Unemployment

Social Security

Disability

Student