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Maternity Leave Match Savings Fund

Applicants must have bills in their name, be pregnant, live in Douglas or Sarpy County, and have a source of income. The applications will be reviewed as received. Please allow up to 15 business days for review and processing of applications. Applications must be filled out completely to be considered.

Questions: Call or email Emily at 402-709-2659 or elarsen@nebraskachildren.org.

General Information

First Name *
Last Name *
Pronouns:
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Country
Address Line 1 *
City *
State/Province *
Postal Code *

Gender

Gender:

Race

Race: (Please check all that apply)

Background Information

What is your current living situation?
Is this living situation one you will remain in for at least 6 months?
Do you have a lease in your name?

Financial Information

Are you getting assistance from other programs or resources in the metro area?
Are you currently employed?
Are you able to save money for this program?
Are you currently enrolled in school? (GED, high school, college, etc.)

Support System

Is your child’s father going to be involved moving forward?
Do you have people you can rely on in time of need?

Current Monthly Budget

FIXED EXPENSES

Questions related to program

Are you willing to work with some type of coach or supportive person?
Are you willing to take a prenatal or newborn class?
Are you willing to participate in a post assessment?
What bills are currently in your name?
How would this program be beneficial to you?

Please remember you will be required to prove that you saved the money before being matched - this will be done by providing a bank statement to Project Everlast.  Fill this form out to the best of your ability and knowledge before turning it in.

I certify all information on this application is true, complete, and accurate. I understand any information given falsely or withheld may make me ineligible for consideration or award. I understand that funds must be used for the purpose stated on this application and that I will be required to submit proof of purchase. I also understand that money received through the Maternity Savings Program is considered income by the IRS and must be reported for tax purposes.

I have read the above statement and agree to the terms of this program.
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