Agency Grant Application Please note all fields must be filled out before submitting. Agency Name Address Lend a Hand will send checks to this address. City State Zip Code Job Title Name Phone Number Email First Name Last Name Address City State Zip Code Age Senior? (65+ years old) Gender Male Female Number of Children Spouse? Total Number of Household Members Veteran? Disabled? Purpose of Grant Rent Gas - Fuel Electricity Oil Transportation Medical Dental Moving Education Appliance Others Amount of Money Requested Total Amount of Money Owed Checks Should Be Issued to: (exact name of check payee) Account Number for Utilities or Other (N/A if not applicable) Situation Briefly describe the situation and why the grant is needed. Other Organizations List any other organizations you are contacting for support. Cover Letter Please upload a PDF or similar file of your cover letter, on your agency's letterhead. Reminder: Grants are made once in a lifetime per family or individual.