The Orphan Society Of America - Empowering Individuals Orphaned By Violence

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Financial Relief Application

The Orphan Society of America (OSA) is committed to empowering individuals orphaned by violence.
The financial relief program is intended to provide temporary financial strain for an individual orphaned
by violence.

• OSA will provide no more than $1,000 per 12 month period.
• OSA will make payments directly to vendors or service providers.
• OSA financial relief is only available to U.S. residents.

Individuals qualify for financial assistance if s/he lost one or both parents to an act of violence, natural or man-made.

Name:
Mailing Address:
City:	State: Zip:
Home Phone:	Work Phone:
Email:
Social Security #

Do you consider yourself…
	African American Asian Caucasian Hispanic/Latino Native Hawaiian/Pacific Islander Other:

Gender:
	Male Female

Which of the following describes you best?...
	I am... An individual who has lost both parents to an act of violence, natural or man-made An individual who has lost one parent to an act of violence and is not currently in the custody of the living parent. An individual who has lost one parent to an act of violence and is currently in the custody of the living parent.

Are you presently in kinship care?
	Yes No
Relative:


Are you presently in foster care?
	Yes No
Foster parents:


Are you presently in a children's home?
	Yes No
Where?:


Do you have a legal guardian?
	Yes No
Who?:

How old were you when you were orphaned?

How old was your mom when she died?

How old was your dad when he died?

Who was your guardian when you were first orphaned?

Who are you currently living with?


Please write a brief essay explaining your situation as an individual orphaned by violence and why you are seeking OSA assistance.


Financial Information:

Annual adjusted gross household income last year $

Please submit ONE of the following documents as proof of your household income:
1. A copy of your current federal income tax form OR 2. A copy of your social security award letter, VA benefits, pension statements or W-2forms, if you do not file a tax return
How many people live in your household (including yourself)?

Does anyone claim you on their tax return?	Yes No
(If yes, a copy of their tax form must be submitted with this application)

How much financial relief are you requesting?
Please describe your need for financial assistance. Be as specific as possible.


Along with your application please submit either an obit or copy of death certificate for your parent(s).

Verification and Release:

I attest that the information I have provided is complete and accurate and I agree that The Orphan Society of America may verify this information. I agree that OSA may disclose information contained in this application to any donors who help fulfill my request. If The Orphan Society of America awards a scholarship to me, I hereby authorize OSA, on a royalty-free basis, to include my life-story as part of its publicity and fund-raising initiatives.


Signature:
Date: