JCAF Online Application

The Joint Coalition Assistance Fund (JCAF)

The Joint Coalition Assistance Fund (JCAF)

This is our JCAF Online Application Form

Be sure to read the instructions before filling out the online application. As a reminder you must answer all questions that apply. Incomplete application forms may be rejected or may be significantly delayed.

A Copy of the Online Application you fill out will be emailed back to you from the current JCAF Volunteer. This will be your confirmation that your application has been received.
If you have attachments that need to be submitted please send them to the current JCAF Volunteer once you receive your copy of the Online Application.
Before pushing send on the Application Form please print a copy from your computer for your records.
Be sure to read the JCAF Instructions before filling out the online application – CLICK HERE
August, September & October 2016 JCAF contact is:
Leslie Garske- 720-635-2686 – email

Joint Coalition Assistance Fund (JCAF)

Date
Member Referring To fill out this form you need to be a member of at least one of the Denver Senior Coalition Chapters. Please fill in all requested applicable information. Incomplete application forms may be rejected or may be significantly delayed.
Your Email
Your Company Name
Your Company Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Your Office Phone
Your Cell Phone
Which Coalition are you a Member of?
Please tell us which Denver Senior Coalition Chapter you are a member ofEast ChapterNorthwest ChapterSouthwest ChapterMember of all 3 Chapters

Applicant A's Information

Applicant A's Name
Applicant's A's Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
What county does the applicant reside in?
JCAF assistance is limited to seniors who live in Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas or Jefferson Counties. Please tell us what county Applicant A lives in.Adams CountyArapahoe CountyBoulder CountyBroomfield CountyDenver CountyDouglas CountyJefferson County
Applicant A's Marital Status
Applicant A's Birthdate
Applicant A's Phone

Applicant B's Information (if applicable)

Applicant B's Name
Applicant B's Marital Status
Applicant B's Birthdate
Applicant B's Phone

Monthly Income

Monthly Income Source & Amount #1
Monthly Income Source & Amount #2
Monthly Income Source & Amount #3
Monthly Income Source & Amount #4
Total Monthly Income

Monthly Expenses

Monthly Expense Description & Amount #1
Monthly Expense Description & Amount #2
Monthly Expense Description & Amount #3
Monthly Expense Description & Amount #4
Total Monthly Expenses

Living Situation

Living Situation
Please describe the living situation such as is the Applicant living alone, with a spouse, family member or other.Living AloneLiving with SpouseLiving with FamilyOther

Assistance Requested

Assistance Requested
Assistance needed because
Applicant can contribute

If request is over $400, two other sources of funding must be contacted

Name of first agency contacted If the request is greater than $400, then two other sources such as an agency or non-profit must have been contacted and you need to share why the funding was denied.
Why was funding denied by the first agency?
Name of second agency contacted Please share the name of the second agency or non-profit organization that you contacted to help with this assistance.
Why was funding denied by the second agency?

Assistance Requested

Total Cost of Assistance Please provide the total cost of the assistance needed. In the next box please provide the amount of funds you are requesting.
JCAF Funds Requested

If Funds Requested is Approved

Supplier Name This is the name of the supplier that we will make the check out to, if your request is approved by the Joint Coalition Assistance Fund.
Contact at Supplier Please provide the name of the person at the Supplier that you are working with.
Supplier's Phone
Supplier's Email (if available)
Supplier's Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Comments

Comments Please share any comments about the Applicant and the assistance requested in this section. Print a copy of this application for your records. If you have attachments that need to be submitted, please send them to the current JCAF Volunteer once you receive your copy of the Online Application. A Copy of this Online Application will be emailed back to you from the current JCAF Volunteer. This will be your confirmation that your application has been received.

Verification

Please enter any two digits *Example: 12
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JCAF Contacts

Aug/Sept/Oct 2016
Leslie Garske
Tel 720-635-2686

Feb/Mar/Apr 2016
Rick Cseak
Tel 720-854-5876

May/June/July 2016
Marsha Harris
Tel 303-770-2987

Aug/Sept/Oct 2016
Leslie Garske
Tel 720-635-2686

Nov/Dec 2016 through Jan 2017
Pat Harper
Tel 303-320-6133
Fax 844-269-8419