Support toward stability

Domestic Abuse Survivor Grant Application

This program is intended to provide financial assistance to survivors as they work toward greater stability and independence.

Your privacy matters. Do not use this form for an emergency. If you are in immediate danger, call 911. For 24/7 confidential support, call the National Domestic Violence Hotline at 1-800-799-SAFE (7233) or text START to 88788.

Confidential application

Tell us what support would help.

Complete the application below. Do not use this form for an emergency.

Domestic Abuse Survivor Grant Application

Demographic Information

Date of Birth:

Safety Information

Are you currently in a relationship with the person who has harmed or abused you? *

YesNoPrefer not to answer

Statement of Need

Explain why you are applying for this grant and how it will support your recovery and stability:

Personal Statement

Share your journey as a survivor of domestic abuse, including your challenges, progress, and hope.

Acknowledgment

I certify that the information provided in this application is true to the best of my knowledge. I understand that all information will be kept confidential and used only to determine eligibility for the grant.

Today's Date: