Application for Assistance

The Mary L. Peyton Foundation (“Foundation”) was created for charitable and educational purposes in 1937 by Joseph C. Peyton, who founded Peyton Packing Company. Today the Foundation is an operating non-profit charity, 501(c)(3), chartered by the State of Texas in 1971. Financial aid and assistance are given by the Foundation to legal residents of El Paso, Texas, who are qualified needy individuals or who are incapacitated and lack sufficient funding for necessities of life, medical attention and equipment, and educational/vocational assistance.

PLEASE NOTE THAT NO FUNDING WILL TAKE PLACE BETWEEN 24 NOVEMBER 2017 - 17 JANUARY 2018

1. APPLICANT INFORMATION

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Social Security Number

Date of Birth

YYYY

Email Address

Preferred method of contact

Please specify how you would like the Foundation to communicate with you.

Marital Status

Please Select One

Children / Ages

Last School Attended

Date

YYYY

Highest Level of Education Completed

Do you own or rent your home?

Please Select One

Amount of Monthly Mortgage or Rent

Please list the names and ages of all persons living at the property. In the case of adults, please indicate whether they are employed

Do You Own or Have Access to a Vehicle?

Name of Applicant's Employer

Employer Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer Phone

(###)

###

####

Position and Job Description

Employment Start Date

YYYY

Employment End Date

If currently employed select today's date

YYYY

If Unemployed, Are You Currently Seeking Employment?

If Unemployed, When Was Your Last Employment

If employed select today's date

YYYY

If Unemployed What Steps Are You Taking to Actively Seek Employment

If employed put n/a

2. ASSISTANCE REQUESTED FROM FOUNDATION

Amount Requested

Please describe Applicant’s Request for Assistance in Detail

What events led to Applicant’s Need for Assistance?

Which Agency, if any, referred Applicant to the Foundation?

If none put n/a

Name and Phone Number of the Case Worker at such Agency:

If none put n/a

What other Sources of Assistance has Applicant Requested or Applied for?

If none put n/a

Has The Applicant Received Funds From Any Other Agency?

If Yes (Amount Received)

3. FINANCES

4. REFERENCES

Please Provide the Name, Address and Phone Number of 2 References Not Related to The Applicant:

Reference 1 Name

First Name

Last Name

Reference 1 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Reference 1 Phone

(###)

###

####

Reference 2 Name

First Name

Last Name

Reference 2 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Reference 2 Phone

(###)

###

####

5. AUTHORIZATION

By Checking the below box the Applicant hereby authorizes the release of the information contained in this Application for Assistance unto the Foundation to evaluate the assistance the Applicant is requesting herein. The Applicant further certifies that the information contained herein is true and correct, and authorizes the Foundation to verify the same. The Applicant hereby agrees that deliberate misrepresentation of any information submitted herein shall automatically subject the Applicant to denial of any assistance requested. THE APPLICANT HEREBY AGREES TO RELEASE AND HOLD HARMLESS THE FOUNDATION, AND ITS DIRECTORS, OFFICERS AND EMPLOYEES FROM AND AGAINST ANY AND ALL LIABILITY, EXPENSE, OR DAMAGE OF ANY KIND OR NATURE AND FROM ANY SUITS, CLAIMS, OR DEMANDS ON ACCOUNT OF ANY MATTER OR THING, WHETHER IN SUIT OR NOT, ARISING OUT OF THE ACTS OR OMISSIONS OF THE FOUNDATION IN CONNECTION WITH THIS APPLICATION.

TERMS AND CONDITIONS

I Agree to the TERMS AND CONDITIONS

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