Find out what programs you qualify for and how much you are eligible to receive:
1. Have you applied for government grants before?
Yes No
2. What is your Date of Birth?
DAY
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
MONTH
January
February
March
April
May
June
July
August
September
October
November
December
/
YEAR
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
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
Before 1920
3. Are you a U.S. Citizen?
Yes No
If you are not a US citizen, please explain:
4. Are you a tax payer?
Yes No
If you do not pay taxes, please explain:
5. Select the categories that apply to you:
Small Business Owner Non-Profit Organization
Disabled Woman
Veteran Minority
Native American Low Income
6. What is your employment status?
Part Time
Full Time
Self Employed
Homemaker
Student
Unemployed
7. How much funding do you need? Select a range and include the exact amount (if you have one).
Range:
Exact Amount:
Over $500,000
$100,000 to $500,000
$50,000 to $100,000
$25,000 to $50,000
$15,000 to $25,000
$10,000 to $15,000
$5,000 to $10,000
Under $5,000
Unsure
8. How are you planning to use the funds? Provide as many details as possible:
9. Do you own a home?
Yes No
10. Do you have any student loan debt?
Yes No
a. If yes, what is the total amount of your student debt?
b. How much of your student debt is left to pay?
c. What school did you attend?
d. Have you consolidated your student loans in the past?
Yes
No
e. Are you finished your schooling and currently repaying your student loan?
Yes
No
11. How many creditors do you owe money to?
12. What is the total amount of debts that you currently owe?
Under $10,000
$10,000 to $20,000
$20,000 to $50,000
$over $50,000
13. What is the dollar amount that you owe to each of your creditors?
Creditor #1:
Creditor #2:
Creditor #3:
Creditor #4:
Creditor #5:
14. What is the status of the credits that you owe?
Current
30 Days
60 Days
90 Days
15. What is your estimate rating of your overall credit profile?
Excellent
Good
Fair
Poor
16. What are your total monthly expenses towards your debts?
17. Do you live in a rural or urban area?
Rural Urban
18. What is your address?
Street Address: *
City: * State: *
AK - Alaska
AL - Alabama
AR - Arkansas
AZ - Arizona
CA - California
CO - Colorado
CT - Connecticut
DC - District of Columbia
DE - Delaware
FL - Florida
GA - Georgia
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MD - Maryland
ME - Maine
MI - Michigan
MN - Minnesota
MO - Missouri
MS - Mississippi
MT - Montana
NC - North Carolina
ND - North Dakota
NE - Nebraska
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VT - Vermont
WA - Washington
WI - Wisconsin
WV - West Virginia
WY - Wyoming
Other
Zip Code: *
19. What is your name?
First Name: * Last Name: *
20. What is your primary email address? *
(Email address can only contain letters, numbers, "@", "-", "_", and ".")
21. What is your primary phone number? *
(Include your area code.)
22. What is your secondary phone number?
(Include your area code.)
23. When is the best time to contact you to discuss your results?
Morning
Afternoon
Evening
Anytime
*(asterisk) = Required field.