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FULL Name (Including Legal Middle Name If You Have One)

Date of Birth

Are you married?

Yes

No

Divorced/Separated

Widowed

Email

Phone

Do you or someone in your family have a mental or physical health issue that has impacted your ability to pay your essential bills?

Yes

No

Has T3 helped you within the last year?

Yes

No

Do you live in Schuylkill County, PA?

Yes

No

FULL Address (including city)

Pls explain your situation and if you or your family have a health need impacting your ability to pay for your essential bills. Pls include illness facing, whether you work, if on disability, amount you need and why.

Dollar Amount Requested

Do you currently attend church?

Yes

No

Occasionally

If You Marked OTHER Above, Type Your Church of Choice AND/OR Any Additional Comments

Share supporting documents (e.g., eviction notice, doctor's notes, etc.)

I authorize Trials to Triumph Foundation to collect, use, and confidentially share the information provided in this application—including information about my health or medical condition—with its authorized staff, application reviewers, participating church representatives, and other parties reasonably necessary to evaluate, verify, process, and administer my request for assistance. I understand that only information reasonably necessary for these purposes will be shared.

*Trials to Triumph Foundation will take measures to protect your personal and medical information. Information will not be sold or used for marketing purposes. Submission of an application does not guarantee financial assistance.

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