Assistance Request Form

GSG does not give cash disbursements. GSG will only will provide coverage for those items deemed necessary, which can be paid directly to the vendors.
To help applicants set expectations, please note that the average award amount is below $1,000 and we DO NOT pay rent or mortgages.

All fields with an * must be filled in

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Please attach required doctors letter confirming medical diagnosis *

Drag & Drop Files, Choose Files to Upload

Please attach letter (preferably from social worker/case manager) confirming financial need *

Drag & Drop Files, Choose Files to Upload

Your Name (Name of person filling out this form) *

First

Last

Phone number of person filling out this form *

Email of person filling out this form *

Are you applying for yourself, or on behalf of someone else? *

• Applying for myself
• Applying on behalf of someone else

If applying for someone else, what is their relationship to you?

Date of birth of intended recipient

Address of recipient/guardian *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Email of recipient/guardian *

Email

Confirm Email

Phone number of intended recipient/guardian *

Amount of assistance request (estimated dollar amount- not a range) *

Description of item/services to be purchased- Please be specific and be prepared to provide proof of need *

How does this item/service fall in line with Granite State Generosity's mission to help those with life changing and life threatening diseases and disabilities, in NH?

Where/how did you learn about Granite State Generosity? *

If you are submitting this form and are NOT a social worker or part of the intended recipients medical team, please provide the name and either e-mail or phone number of your social worker

Acknowledgement (please check in agreement) (copy)

• I understand that completion of this request DOES NOT guarantee that assistance will be provided
• To the best of the submitters knowledge, the proposed recipient is experiencing financial hardship

Submit