Instructions for Completing the Monetary Request Application

A Professional is defined as a Social Worker, Case Manager or Healthcare Provider.

A Consumer is defined as person or family in need and must be a woman or girl.

Good Friends of The First State reserves the right to approve or decline any application based on its sound judgement and discretion.
Please complete all required fields, incomplete applications will be denied.
Incomplete applications will expire after 14 days and must be resubmitted.
Requests must be for a crisis (unforeseen event that has prevented client from affording the expense).
There must be sufficient justification and supporting documentation for the request.
Explanation must be given of how the balance will be paid if the total expense is greater than $1,500 (payment plan, contribution from another agency etc.).
Information must be supplied on all members of the household (HH) and their total income. We compare the HH information to the Federal Poverty Tables in determining financial eligibility. Please verify DSS eligibility information or other data sources if you have access.
Documentation (statement, bill, ledger, invoice, etc.) MUST be CURRENT and in the CONSUMER’S NAME:

Rent: lease, current statement, eviction letter, if applicable.
Utilities: current statement, disconnect date/letter, if applicable.
Auto Loan: current statement, repossession letter, if applicable.
Auto Repairs: owner car, 2 estimates.
Furniture, Medical Supplies, Services (e.g., pest control), etc.: 2 estimates with breakdown of cost, delivery, etc. We only buy new items when used items aren’t available.
Home Improvements: 2 estimates from reputable contractors, mortgage statement. We will not consider a residence not owned by the consumer.
Medication Request: name of the medication, the condition it will treat, and cost. If your client is between the ages of 18-49, please indicate if they are receiving Medicaid and if they are covered by health insurance. Be sure to check with Med-Assist to see if your client is eligible for services before submitting an Application to Good Friends of The First State.