We Are Here for You

Apply for Financial Assistance

Taking this step shows courage. Please know that every application is reviewed with care, compassion, and complete confidentiality. You are not alone.

Tell Us About Your Situation

Please fill out the form below as completely as you can.

1. Contact Information

Your basic contact and address details.

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

Street Address *

City *

State *

ZIP Code *

2. Family

Tell us about your household.

Marital Status *

Total Household Size *

Number of Dependent Children

Ages of Children (if applicable)

3. Employment & Income

Help us understand your current financial situation.

Employment Status *

Employer Name

Gross Monthly Income *

Other Monthly Income

Source of Other Income (if applicable)

Approximate Total Monthly Expenses

4. Tell Us About Your Situation

Your information is kept strictly confidential. Please share as much as you are comfortable with.

Please describe your current situation and need *

How did you hear about Terracotta Foundation, Inc.?

5. Certification & Agreement

I certify that all information provided in this application is true and accurate to the best of my knowledge. I understand that providing false information may result in disqualification from assistance. *

I understand that Terracotta Foundation INC will review my application and that assistance is not guaranteed. I agree to allow the Foundation to contact my references and verify the information provided. *

After submitting, a member of our team will reach out to you within 3–5 business days.