DWC Assistance Fund Request Form - The Destin Woman's Club

Name:

Phone:

Address:

City

State/Province

Zip/Postal

Email:

Mailing Address:

City

State/Province

Zip/Postal

Marital Status:

Single

Married

Divorced

Employer:

Occupation/profession:

Are you currently unemployed?:

I am currently unemployed

Are you receiving unemployment assistance?

Yes

No

Are you a non-profit organization?:

Yes

No

Non-Profit Organization Information

Organization Name:

Contact Name

Organization Address:

City

State/Province

Zip/Postal

Organization Email Address:

Phone

Please tell us about your situation and the reason for your request (with as much detail as possible):

Assistance Requested

If your request includes assistance for rent/mortgage or utility bills, please email copies of mortgage / utilities bills and other supporting documents using the email link below.

Total Amount of Assistance Requested ($USD)

Monthly rent/mortgage:

Amount past due:

Name of Landlord/Mortgager:

Electric Bill

Amount past due:

Electric company name:

Acct #:

Water Bill

Amount past due:

Water company name:

Acct #:

Gas Bill

Amount past due:

Gas company name:

Acct #:

Will you be sending supporting information?

No

Yes

Click to Send Attachments To Committee

Have you requested assistance from another organization?

Yes

No

If yes, please explain (if you feel comfortable sharing this information):

If your request includes assistance for other items, not stated above, please provide detailed information:

How did you hear about us?

Signature:

Clear

Date:

Please Note: All Applicants must reside in Walton or Okaloosa Counties, unless Executive Board approves and are subject to the same review process. All requests must be reviewed and approved by the Destin Woman’s Club “DWC” Executive Board, and will be treated with the utmost confidentiality. Although the DWC Executive Board strives to reach each decision with full consideration for each request, regardless of Applicant’s gender, age, race or religion, and in a very timely manner, additional information may need to be considered before such decision can be determined. Your patience & understanding is appreciated. DWC is a 501(c)(3) equal opportunity organization comprised of all volunteer women.

Revised August 2023