Financial Assistance Application

Manna on Main Street's Financial Assistance Application

Are you a resident of North Penn School District?

Yes

You are not eligible for Manna's non-COVID financial assistance. Please call Community Connections for additional resources at 610-278-3522.

Your Information

First Name *

Last Name *

Date of Birth *

xx/xx/xxxx

Address *

Address

City

State/Province

Zip/Postal

Sex/Gender

Race

Ethnicity

Phone *

Email *

Other Adults in Household

Are there any other adults in the household? *

Yes

If yes, how many?

Information for Other Adults in Household

First Name *

Last Name *

Date of Birth *

Relationship to Primary Applicant *

Sex/Gender *

Race

Ethnicity

Add Remove

Minors (Under 18) in Household

Are there any minors (under 18) in the household? *

Yes

If yes, how many?

Minors (Under 18) in Household

First Name *

Last Name *

Date of Birth *

Relationship to Primary Applicant *

Sex/Gender *

Race

Ethnicity

Add Remove

Mortgage - Amount Needed

Are you receiving other assistance for these payments?

Yes

Rent - Amount Needed

Are you receiving other assistance for these payments?

Yes

Security Deposit - Amount Needed

Are you receiving other assistance for these payments?

Yes

If you have you been approved for a new rental property, provide the full address:

City

State/Province

Zip/Postal

Country

New Monthly Rent

Estimated Utilities

Electric - Amount Needed

Are you receiving other assistance for these payments?

Yes

Sewer/Water - Amount Needed

Are you receiving other assistance for these payments?

Yes

Gas Heat/Hot Water - Amount Needed

Are you receiving other assistance for these payments?

Yes

Oil - Amount Needed

Are you receiving other assistance for these payments?

Yes

Other - Type and Amount Needed

Please describe what led to your financial need (ex. job loss, illness, unexpected expense) *

Monthly NET Household Income

Please include income for all household members

Work Earnings *

Retirement/Pension *

SNAP Benefits

Social Security Income/Social Security Disability Income

Child Support

Disability/Unemployment/Workers Comp

Other

*All income must be documented income.

Monthly Expenses

Housing - Rent or Mortgage *

Utilities - Electricity *

Utilities - Oil/Gas *

Utilities - Trash *

Utilities - Water/Sewer *

Cable/Internet/Home phone *

Cell phones *

Transportation - Auto Payment *

Transportation - Auto Insurance *

Transportation - Public Transit Fare *

Home Owner/Renters Insurances *

Student Loans *

Daycare Costs *

Child Support *

Other *

Manna on Main Street will safeguard your personal information. In certain situations, we may need to contact other organizations to obtain or share information to better assist you. Your information will only be used within the scope of our services for food assistance and for rental, utility or other financial assistance. Note that signing this form gives Manna permission to text or email you updates. *

I have read and understand

Manna does not discriminate based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted. *

I have read and understand

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