- Hardship/Scholarship

 

 

ARK TRANSITION VILLAGE

HARDSHIP/SCHOLARSHIP REQUEST FORM


Participant Name: _______________________________________________

Date of Request: __________________________

Expected Move-In Date (if applicable): __________________________


TYPE OF FINANCIAL ASSISTANCE REQUESTED
(Please select one)

☐ Hardship Assistance (Repayable)

I am requesting a temporary financial hardship arrangement. I understand that any deferred program fees must be repaid and that repayment will begin once I am employed and receiving income.


☐ Scholarship Assistance (Non-Repayable)

I am requesting scholarship assistance. I understand that approved scholarship funds do not need to be repaid, but that scholarship approval does not exempt me from house rules, program expectations, or behavioral requirements.


REASON FOR REQUEST

Please briefly explain your current financial situation and why you are requesting hardship or scholarship assistance.

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________


EMPLOYMENT & INCOME INFORMATION

Current Employment Status (check one):

☐ Employed
☐ Unemployed
☐ Seeking Employment
☐ Other: __________________________________


If employed, place of employment:

_______________________________________________________________


Expected start date (if applicable):

_______________________________________________________________


ACKNOWLEDGMENT & AGREEMENT

I understand that all requests are reviewed on a case-by-case basis and that approval of financial assistance is not guaranteed. I understand that if I am approved for Hardship Assistance, I am responsible for repaying any deferred program fees in accordance with an agreed-upon plan.

I understand that if I am approved for Scholarship Assistance, approved fees are not required to be repaid. I further understand that receiving financial assistance does not guarantee continued residency and does not exempt me from compliance with all Ark Transition Village policies, house rules, and program expectations.


Participant Signature: __________________________________________

Date: __________________________


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STAFF USE ONLY
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TYPE OF ASSISTANCE APPROVED (check one):

☐ Hardship Assistance (Repayable)

☐ Scholarship Assistance (Non-Repayable)

☐ Denied


If approved, indicate:

☐ Full
☐ Partial
☐ Time-Limited

Timeframe: __________________________


Approved Amount (if applicable): $____________________________


Repayment Plan Required:

☐ Yes
☐ No


Review Date (if applicable): ___________________________________


CRRA / Authorized Staff Name:

_______________________________________________________________


Signature:

_______________________________________________________________


Date:

____________________________