2014-2015YOUNG STUDENT PARENT SUPPORT INITIATIVE

EMERGENCY FUNDS APPLICATION

Please checkwhich type of emergency for which you are applying

Child care _____ Housing ______Transportation______Books______Other______

How much money are you requesting?______

1.Name (Last, First, Middle)

2. Email Address

/

3. WSU Tech ID #

/

4.Birth Date

5. Permanent Home Address

/

6. Telephone Number

Cell:
Work:

7. City, State, Zip Code

/

8.Enrollment Status

___ Graduate Student
___ Undergraduate
Major______
Anticipated Graduation Date: ______

9.If you are requesting fund for childcare:

Have you applied for a CCampis Child Grant ______

Have you applied for a MN Child Care Grant______
Have you applied for a SAF grant ______

10. What is your family size? ______

What is your family income? $______/Monthly

(You may be asked to supply documentation of income, EG. Tax return, paycheck stub, etc.

a. Are you Pell Grant ELGIBLE: ___ yes ___no (you do not need to receive funds, just eligible)

b. Do you currently receive Pell Grant funding? ___ yes ___no

11. How many semesters have you received Emergency Funds assistance? _____

Are you or your spouse receiving child care assistance from some other source?

_____ no ____ yes (If yes, list sources & amount received)
  1. ______
  2. ______
  3. ______

12. Briefly explain your need for emergency assistance and how you will be able to provide documentation of need (such as day care bill, notice of overdue rent/mortgage, estimate of amount for auto work, etc.)?

If emergency funds are for day care assistance , please provide name and license number
______
13. Do you have direct deposit set up with Student Accounts?______
Do you have a balance in your student account?______
I understand and accept the obligation to provide a written report to the program of any changes in information provided on this application within 10 days of the change. Changes may include, but are not limited to my enrollment, family size, family income, receipt of MFIP benefits, etc.
I give permission to the program to seek any information to determine the need to receive emergency funds from the MSPSI program.
I certify that the information on this application is true and correct and I promise to provide additional documentation if requested. I promise to use the funds for which I have requested them for. I understand that this form is used to establish eligibility for the receipt of Emergency Funds from the MSPSI grant program and that if I purposely give false or misleading information on this form, I may be asked to return any funds distributed to me; and such action may result in the forfeiture of participation from this program.
______
Applicant’s Signature Date (Month/Day/Year)
(To be completed by program)
Students Total Request $______
Type of fund requested ______
Award per term: Fall $______Spring $______Summer $______
Total for the academic year $______
Additional Comments: ______
______
______
Debra Hammel
Assistant Director
Young Student Parent Support Initiative
Winona State University
______
Date (Month/Day/Year)