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Home
Who We Are
Our Team
Our Families
Agency Partners
Community Partners & Sponsors
Media Coverage
Our Programs
Back to School Assistance
Kindness Warrior Program
Holiday Assistance
Stabilize Families
Donation & Empowerment Center
How You Can Help
In-Kind Donations
Volunteer
Donate
Contact us
Donate
Holiday Assistance
Gold & Diamond Source Gives Back
Agency Referral Application
Law Enforcement Pick-Up Request
Back to School Assistance
Referral Application Link
Please call 2-1-1 and visit
https://www.crisiscenter.com/
for additional local resources if you are not currently working with a nonprofit, law enforcement officer or case manager.
Referral Application
Agency that is making a referral
*
Law Enforcement Agency
Certified Domestic Violence Center
Human Trafficking Safe House
Tampa Bay Area Hospital
Certified Therapist
Wheels of Success
BabyCycle
The Kind Mouse
Dress for Success
R U Safe
GFWC
Wheelchairs 4 Kids
Pepin Academies
Voices for Children
A Kids Place
Ready for Life
Angels Against Abuse
The Spark Initiative
Joshua House
Pace Center for Girls
Girls Inc.
Clothes to Kids
The Kimberly Home
Heels to Heals
EmpowHERment
Rebekah's Angels
Saleh Freedom
Hope Services
Suncoast Center
Alpha House
Champions for Children
Mary & Martha House
Hope for Her
Mattie Williams Neighborhood Family Center
Remember Me
Our Children Have Rights
Healthy Start Coalition Pinellas County
Positive Spin
Centre of Women
State Attorney's Office
HATB Board Member
Agency Contact Name
*
First
Last
Phone Number of Agency Contact
*
Email of Agency Contact
*
Applicant Photo ID
*
*All information below on application should reflect information on individual applying for Hands Across the Bay assistance*
Applicant Full Name
*
First Name
Middle Name
Last Name
Suffix
Applicant Date of Birth
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
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1971
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1968
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1965
1964
1963
1962
1961
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1953
1952
1951
1950
1949
1948
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1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Applicant Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Applicant Phone Number
*
Applicant Email Address
*
Ethnic Background(for statistical purposes)
*
African American
Asian
American Indian or Native American
Caucasian
Hispanic
Native Hawaiian or Other Pacific Islander
Two or More
Prefer not to say
Other
Please list Applicants household member names and date of birth.
*
*Please include adults & children*
Is the Applicant currently employed?
*
Yes
No
Where is the Applicant Currently Employed?
*
Please explain why the Applicant is currently unemployed.
*
Please upload the applicants most recent pay stub
Drop files here or
Accepted file types: jpg, jpeg, png, pdf.
What type of assistance is your client in need of?
*
Utility Assistance
Transportation
Visit to Donation Center(Items include hygiene, kitchen supplies, bedding, cleaning supplies, clothing, etc.)
DV Safety Assistance
Child & baby needs
Advice/resources
Grocery Assistance
School Supplies
Clothing
Other
Select All that Apply
Please explain the circumstances surrounding the request for assistance.
*
Does the applicant receive food stamps?
*
Yes
No
I have applied recently and am still waiting to hear back.
How much does the applicant receive per month?
*
Enter USD
Is the Department of Children and Families (DCF) involved?
*
Yes
No
Please give the name and phone number of your case worker.
Do you receive WIC (Woman, Infants & Children)?
*
Yes
No
Do you receive housing assistance (ex: HUD, Section 8, etc.)?
*
Yes
No
Have you or anyone in your household ever been arrested, convicted of or plead guilty to a crime?
*
Yes
No
To help us evaluate your application, please describe the nature of the crime and your subsequent rehabilitation.
*
Do you have a car/reliable transportation?
*
Yes
No
Total Household Monthly Income
*
Include all job-related income, social security, cash assistance, and child support.
Total Monthly Expenses
Remaining Funds After Expenses
*Bank Statements required upon request. This is so we can make sure there is no unnecessary spending*
I agree upon my final approval of services to provide supporting documentation for the circumstances at hand in relation to my request for assistance.
*
Yes
No
Application Statement: I have read and fully understand the questions asked in this application. I certify that all of the answers I have given are true, accurate, and complete. I unerstand that the omission and/or misrepresentation of any fact from or on this questionnaire will result in immediate rejection of my application. Unless I noted otherwise, I authorize Hands Across the Bay to contact all of my personal references and do a criminal background check. If assisted, I agree to abide by all rules and regulations of Hands Across the Bay. I understand and agree that nothing in this application shall constitute an offer, a contract, or a guarantee of assistance. I understand that any decision is contingent upon my successful completion of all of the Company's lawful pre-assistance checks, which may include a background check. I agree to execute any consent forms necessary for the Company to conduct its lawful pre-assistance checks. By signing below, I agree to all of the terms stated here.
Signature
*
Date of Application
*
MM
DD
YYYY
Consent
I agree to the privacy policy.
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