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CYI Support Services Fund

Applications must be filled out by the person requesting funds. Exceptions may be made due to disability if stated on the application. Applications will be reviewed as received. Please allow up to 15 business days for review and processing of applications if they are filled out completely. Questions: Call Glenda Fulkerson at 402.384.4670

Please remember you will be required to prove that you spent the money the way you requested ‐ this will be done by providing a receipt to Project Everlast. Fill this form out to the best of your ability and knowledge before turning it in to Glenda Fulkerson.

General Information

Total amount requesting:
Pronouns:
Additional Details
Gender
Race
Please check all that apply.
Background Information
Are you pregnant or expecting a child?
(check ONE)
What is your current living situation?
Is this living situation one you will remain in for at least 6 months?
Financial Information
Are you getting assistance from other programs or resources in the metro area?
Are you currently employed?
Are you currently enrolled in school? (GED, high school, college, etc.)

Current Monthly Budget

FIXED EXPENSES
TOTALS

Applicant Statement

Please describe your need in detail, including specific amount you request, sustainability plan, and why you are unable to meet this need. In the sustainability plan include how you plan to manage this need in the future. The more information you provide, the more helpful it will be for the committee to review and approve your application.  

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 Support Services Fund is considered income by the IRS and must be reported for tax purposes. 

Check here if you agree
Today's Date
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I understand that I must provide documentation for my application to be accepted. Any fraudulent documentation will result in being disqualified for a minimum of 1 year.

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