Request Assistance

Women With Willpower provides one – time assistance to eligible women in our community, who are currently employed and experiencing a temporary financial hardship.

Submitting this request does not guarantee approval or financial assistance. Each request is reviewed individually based on eligibility, circumstances, documentation provided, and available funding. Assistance, when approved, is paid directly to the appropriate vendor or service provider.

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Name *

First

Last

Email *

Phone Number *

Address *

ZIP Code *

How long have you lived in Lake Havasu City? *

Household Members *

List each person in your household, their age, and relationship to you.

Current Employer *

Please provide the name of your current employer.

How long have you been with your current employer? *

Gross Monthly Income *

Enter your total monthly income from your current employment before taxes.

Monthly May

Child Support

Alimony

SSI / Social Security / SSDI

Disability Income

Retirement/Pension Income

Spouse/Partner Income

Roommate/Other Household Member Income

Government Assistance

Other Income

Amount of Assistance Requested *

Enter the dollar amount you are requesting.

What are you requesting assistance with? *

Please explain the expense you are requesting help with and your current circumstances.

Resources Contacted *

List each resource you contacted, the date contacted, who you spoke with, and the outcome.

Do you need a list of resources to contact?

• Yes
• No

What caused your temporary financial hardship? *

Please explain what happened and why you are requesting assistance at this time.

How will this assistance provide a “hand up”? *

Please explain how this one-time assistance will help you become financially stable, moving forward.

Payee/Vendor Name *

Who should Women With Willpower pay if your request is approved?

Payee/Vendor Phone Number *

Payee/Vendor Address *

Account Number (if applicable)

Enter the account number associated with the bill or service, if applicable.

Vendor Contact Person *

Are you able to pay part of this bill? *

• Yes
• No

If yes, how much?

How did you hear about us?

Would you like to volunteer with WWW?

• Yes
• No

May we share your story?

• Yes
• No

Your answer will not affect your request for assistance.

Applicant Acknowledgement *

• I understand that submitting this request does not guarantee approval or financial assistance.

Certification *

• I certify that the information provided in this request is complete and accurate to the best of my knowledge.

Required Documentation *

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Please upload a copy of your photo ID, proof of current income, and the bill, estimate, or invoice related to your assistance request. You may upload multiple files.

Submit