Philanthropy

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POLITICAL & CORPORATE ADVISOR
PSYCHOLOGIST

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Directions:

This form must be completed by the office of the Philanthropy Referral Partner*.
To receive the funds, an active U.S. bank account is required.

To ensure validity of financial need, unsolicited requests for funding cannot be accepted.

Partner Referral Form

FUNDING REQUEST

Name of individual experiencing the financial crisis (first name, last name):

Name must match the name on the bank account.
If the funding recipient is a family, enter information for the adult family member listed as the bank account holder.

Home address (street address):

Mailing address (if different from home address):

Telephone number of funding recipient:

Full name of bank account holder:

Social Security Number of bank account holder:

Bank account number:

Is there a negative bank account balance?

YES

Does the applicant have a PayPal account?

YES

Funds will be used for:

emergency housing

food/groceries

children's clothing, diapers, etc.

other financial crisis/need

Bank routing number:

If the bank account is negative, what is the negative bank account balance?

What is the PayPal email address?

Provide details of the specific need.

CERTIFICATE OF NEED

Referral Partner type

political office

corporate office

Name & Title of Elected Official

State

Elected Official's email address

Name of Chief Executive Officer

Name of Corporation

CEO's email address

Name of Chief of Staff / Representative

Direct phone number

Email Address

Name of Executive Assistant / Representative

Direct phone number

Email Address

Thanks for submitting!

* Philanthropy Referral Partners are political or corporate leaders who, due to legislation or other restrictions, are prevented from giving direct financial support to private citizens.

DR. RENEE CARR THE PROBLEM SOLVER®

#TheProblemSolver

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